Meadowbrook Acres
Inspection history, citations, penalties and survey trends for this long-term care facility in Charleston, West Virginia.
- Location
- 2149 Greenbrier Street, Charleston, West Virginia 25311
- CMS Provider Number
- 515134
- Inspections on file
- 21
- Latest survey
- November 6, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Meadowbrook Acres during CMS and state inspections, most recent first.
Three residents with care plans or orders for bed rails to assist with mobility, transfers, or repositioning were observed without the required side rails in place. The DON confirmed that the bed rails were not present as specified in the care plans or orders.
Surveyors found that staff did not follow physician orders for side rail use and failed to perform required neurological checks after unwitnessed falls. Multiple residents who had orders for side rails to assist with mobility and repositioning were observed without them in place, and a resident with a history of falls did not receive neuro checks as per facility policy. The DON confirmed these omissions during interviews.
A registered nurse administered medication to a resident during a Bible Study activity, entering a closed room marked for the event. The nurse indicated this practice occurs even when not behind schedule, and an activity assistant confirmed medications are often given during activities. This action did not comply with the facility's policy requiring privacy during medication administration.
A resident with a known history of wandering and multiple exit-seeking incidents was able to elope from the facility several times over nine months, including one event where the resident was found at a local ER. Despite being identified as high risk and wearing a wander guard bracelet, the care plan interventions were not updated to include increased supervision or monitoring, and staff failed to ensure facility doors were properly secured, directly contributing to the resident's ability to leave the premises.
A resident with a known history of exit-seeking behavior and multiple successful elopements was able to leave the facility after staff failed to ensure a door was properly latched. Despite risk assessments and a wander guard bracelet, the resident's care plan and supervision were insufficient to prevent repeated elopement attempts, and documentation of discussions about higher-level interventions was lacking.
A janitor's closet containing hazardous chemicals and a medication cart were both found unlocked and unattended. Additionally, a resident was observed using a vape inside the building before reaching the designated supervised smoking area, contrary to facility policy and the resident's care plan. Staff confirmed these lapses in supervision and safety procedures.
Surveyors found that the facility did not consistently complete required narcotic medication logbook reconciliations at shift changes in two halls. Multiple entries and nurse signatures were missing for various shifts, and these documentation lapses were confirmed by the Administrator during the survey.
A rack of plate lids was found stored against an open utility-room door in the kitchen, where dirty mops, rags, and chemicals were present. The Dietary Manager acknowledged this was not an appropriate storage location, potentially affecting all residents receiving meals from the kitchen.
A resident was left without a meal while seated with others who were eating, as staff served seven additional tables before the issue was noticed and addressed. The DON confirmed the resident should have been served alongside their tablemates, indicating a lapse in ensuring dignity and respect during meal service.
A resident was started on Zoloft (Sertraline HCI) for anxiety disorder without a signed consent form in the medical record. The DON confirmed that consent was not obtained prior to initiating the psychotropic medication.
A resident was discharged home after the last covered day of Medicare Part A services, but the required Notice of Medicare Non-Coverage (NOMNC) was provided only 24 hours in advance instead of the mandated 48 hours. This was confirmed by the BOM during a review of beneficiary protection notifications.
A resident with dementia, blindness, and limited mobility experienced two incidents where nurse aides failed to use a required Hoyer lift during transfers, resulting in injury and pain. Although facility policy required all nurse aides to be re-educated after such events, only the aides directly involved received training, and the administrator confirmed that the rest of the staff did not receive the mandated re-education.
A resident dependent on staff for ADL care was found covered in dried feces, with both the resident and bed soiled due to lack of timely hygiene assistance. Staff statements and interviews confirmed the failure to provide necessary care, and the incident was reported as neglect to authorities.
A resident's monthly pharmacy reviews for two months were not signed by the facility physician, and there was no documentation to show whether the physician agreed or disagreed with the pharmacy's recommendations. The administrator confirmed the absence of physician signatures on these reviews.
A resident was prescribed Zoloft 50mg daily for anxiety disorder without a signed consent form in the medical record. The DON confirmed the absence of the required consent documentation for this psychotropic medication.
A resident was found to have two medications—Eye Scrubs External Pad and Metoprolol Tartrate—documented in their medical record without corresponding diagnoses. This lack of documentation was confirmed by the Administrator and DON during the survey.
The facility failed to implement comprehensive care plans for two residents with behavioral issues. One resident was involved in an incident of inappropriate touching, while another punched a fellow resident. Despite these incidents, their care plans lacked behavioral focus, goals, or interventions. The administrator acknowledged these deficiencies.
Failure to Implement Bed Rail Care Plan Interventions
Penalty
Summary
The facility failed to develop and implement care plans for the application of bed rails for three residents who had physician orders or care plan interventions specifying the use of side rails for assistance with bed mobility, transfers, or repositioning. For one resident, current orders indicated the use of bilateral upper side rails to assist with bed mobility and transfers, and the care plan included this intervention; however, observation revealed that no side rails were present on the bed. This finding was confirmed by the Director of Nursing (DON). Similarly, another resident had a fall care plan intervention for half bilateral side rails to the head of the bed to increase independence with positioning and personal care, but observation showed the resident lying in bed without the side rails in place as specified in the care plan. The DON confirmed the absence of side rails. A third resident had a care plan order for bilateral quarter side rails to assist with repositioning and bed mobility, but observation again revealed no side rails in place, which was acknowledged by the DON. These findings demonstrate that the facility did not implement the care plan interventions related to bed rail use as ordered for these residents.
Failure to Follow Physician Orders for Side Rails and Neurological Checks
Penalty
Summary
The facility failed to provide care in accordance with professional standards by not following physician orders for side rail implementation and neurological checks for four residents reviewed for fall interventions. Specifically, several residents had physician or care plan orders for bilateral or quarter side rails to assist with bed mobility and repositioning, but observations revealed that these side rails were not in place as ordered. The Director of Nursing confirmed in each case that the side rails were missing despite the documented orders and care plans. Additionally, a resident who experienced an unwitnessed fall did not receive neurological assessments as required by the facility's policy, which mandates a specific schedule of neuro checks following such incidents. The Director of Nursing acknowledged that these assessments were not performed for the resident after the unwitnessed fall, despite the policy and the resident's history of multiple falls. These findings were based on record reviews, staff interviews, and direct observations during the survey process.
Medication Administration During Activity Lacks Privacy and Dignity
Penalty
Summary
A deficiency was identified when a registered nurse entered a closed recreation room during a Bible Study activity and administered medication to a resident. The door to the room was marked with a sign indicating that Bible Study was in progress. The nurse stated that medications are sometimes given during activities or in the dining room, not due to being behind schedule but to expedite the process. An activity assistant confirmed that medications are routinely administered during activities. Review of the facility's medication administration policy revealed a requirement to provide privacy during medication administration, which was not followed in this instance.
Failure to Prevent Repeated Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and monitoring to prevent repeated elopements for a resident identified as being at risk for wandering and exit-seeking behaviors. Over a nine-month period, the resident exhibited more than 20 instances of exit-seeking or attempted elopement, with five successful elopements, including one incident where the resident was found at a local emergency room after leaving the facility. Documentation showed that the resident had a history of wandering, was assessed as high risk for elopement, and wore a wander guard bracelet since admission. Despite these risk factors and repeated incidents, the care plan interventions remained unchanged and did not include increased supervision or more frequent monitoring. Staff interviews and record reviews revealed that on the day of the most recent elopement, three evening shift staff members failed to ensure that a facility door was properly latched, which allowed the resident to leave undetected for approximately two hours. The facility's elopement policy in place at the time had not been updated since 2013, and interventions in the care plan were limited to distraction techniques and routine checks of the wander guard device, without escalation in response to the resident's ongoing behaviors. There was also a lack of documentation regarding discussions with the resident's family about potential placement in a more secure unit.
Failure to Prevent Repeated Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent repeated elopements for a resident identified as being at risk. Record review showed that the resident had a history of exit-seeking behavior, with documentation of at least 20 incidents of attempting to leave the facility and five successful elopements over a period of several months. Despite being assessed as at risk for elopement and having a wander guard bracelet in place, the resident was able to leave the facility when staff failed to ensure a door was properly latched. The resident was later found at a local emergency room after being missing for approximately two hours. The care plan for the resident included interventions such as involving the resident in activities, providing diversions, and ensuring the wander guard bracelet was worn and checked, but these measures were not sufficient to prevent repeated elopement attempts. Staff interviews revealed that discussions about moving the resident to a locked unit were not documented, and the DON acknowledged that more frequent monitoring, such as one-on-one supervision or 15-minute checks, was not implemented. The facility's elopement policy in place at the time had not been updated since 2013.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents. Observations revealed that a janitor's closet on the B hall was repeatedly found unlocked and unattended, containing various cleaning chemicals such as Clorox Clean-up, Sani-Clean 2 spray, and bleach germicidal wipes. The Maintenance Assistant confirmed that the closet should always be locked but stated the lock was broken and was unsure how long it had been in that condition. Additionally, a medication cart on the B Hall was observed unlocked and unattended, and an LPN confirmed that the cart should not be left in this state. A resident who was permitted to smoke a vape (electronic cigarette) only at designated times and in a designated outdoor area with staff supervision was observed using the vape inside the building before reaching the designated area. The resident's care plan and facility policy required the vape to be used only under supervision and in the specified location, with the device stored in the medication cart and charged by nursing staff. The staff member accompanying the resident acknowledged that the resident was not supposed to use the vape before exiting the building, and the Administrator confirmed this expectation.
Failure to Properly Reconcile Narcotic Medication Logbooks at Shift Changes
Penalty
Summary
The facility failed to ensure proper reconciliation of the narcotic medication logbook for both A Hall and B Hall, as observed during the medication administration process. On multiple occasions between 02/18/25 and 04/09/25, required entries and nurse signatures were missing for various shift changes. Specific deficiencies included the absence of entries for entire shifts and missing nurse signatures for both coming on and going off duty. These lapses were confirmed by the Administrator, who acknowledged that the reconciliation process was not completed as required on the identified dates. The findings were based on direct observation, record review, and staff interviews. The narcotic medication logbooks for both halls showed repeated failures to document the transfer and accountability of controlled substances at shift changes, as required by facility policy and regulatory standards. No information was provided regarding specific residents affected or their medical conditions at the time of the deficiency.
Improper Storage of Plate Lids Near Utility Room
Penalty
Summary
Surveyors observed that a rack of plate lids was stored directly against an open utility-room door in the kitchen. The utility room contained a mop sink, dirty mops, rags, and chemicals. This storage practice did not align with professional standards for food service safety. During an interview, the Dietary Manager acknowledged that the plate lids should probably not be stored in that location with the door open. This deficiency had the potential to affect all residents who received their nutrition from the kitchen, as improper storage of food service items was observed.
Resident Not Served Meal with Tablemates During Lunch Service
Penalty
Summary
During a meal service observation, a resident was seated at a table with two other residents and a visitor who were all eating lunch, while the resident watched without being served their meal. The surveyor noted that seven additional tables were served before intervening. The Director of Nursing confirmed that the resident should have been served at the same time as the others at the table. This incident demonstrated a failure to treat the resident with respect and dignity during meal service, as the resident was left waiting while others around them ate.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
Facility staff failed to ensure that a resident and/or their medical representative was informed of and participated in the decision to initiate a psychotropic medication. Specifically, a physician order was present for Zoloft (Sertraline HCI) 50 mg daily for the treatment of anxiety disorder for one resident. Upon review of the medical record, there was no signed consent form for the administration of Zoloft. The Director of Nursing confirmed during an interview that no such consent form existed for this resident.
Failure to Provide Timely Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to provide timely notification of Medicare non-coverage to a resident who was discharged home following the last covered day of Medicare Part A services. Specifically, the Notice of Medicare Non-Coverage (NOMNC) was issued only 24 hours prior to the end of covered services, rather than the required minimum of 48 hours as outlined in the CMS-10123 form instructions. This deficiency was identified during a review of records and confirmed by the Business Office Manager, who acknowledged that the notification was not provided within the mandated timeframe. The review focused on one of three residents sampled for beneficiary protection notification, with the facility census at 54 residents at the time of the survey.
Failure to Re-Educate All Nurse Aides After Substantiated Neglect
Penalty
Summary
The facility failed to implement its policy regarding the re-education of all nurse aide (NA) staff following substantiated allegations of neglect involving a resident with dementia, blindness, limited functional mobility, and generalized muscle weakness. In two separate incidents, nurse aides did not follow the resident's care plan, which required two-person assistance and the use of a full body Hoyer lift for transfers. In both cases, the aides involved did not use the lift, resulting in a skin tear in one incident and pain in the resident's leg in another. Although the facility's policy required that all NAs be re-educated after such incidents, documentation showed that only the directly involved aides received re-education. There was no evidence that the rest of the NA staff received the required training. The administrator confirmed that not all NAs were re-educated as stipulated by the facility's policy.
Failure to Provide Timely ADL Care Resulting in Resident Neglect
Penalty
Summary
A resident who was dependent on staff for activities of daily living (ADLs) was found covered in dried feces from head to toe, as reported by her son and confirmed by both a nurse aide and a registered nurse. The incident occurred on 11/17/24, and documentation showed that the resident and her bed were soiled with dried feces, indicating a lack of timely ADL care. The facility's records confirmed that the resident did not receive necessary assistance with hygiene and care according to her assessed needs, resulting in the incident being reported to state and local authorities for neglect. The deficiency was substantiated through staff statements and interviews, including confirmation from the Director of Nursing that the resident did not receive timely care.
Physician Review of Pharmacy Recommendations Not Documented
Penalty
Summary
The facility failed to ensure that two monthly pharmacy reviews for one resident were reviewed and signed by the facility physician. Specifically, a record review for one resident revealed that the pharmacy reviews for two separate months were not signed by the physician, and there was no documentation indicating whether the physician agreed or disagreed with the pharmacy's recommendations. This deficiency was confirmed by the facility administrator, who acknowledged that neither of the pharmacy reviews had been signed by the physician as required.
Lack of Consent for Psychotropic Medication
Penalty
Summary
A deficiency was identified when a review of the medical record for one resident revealed a physician's order for Zoloft (Sertraline HCI) 50mg daily for anxiety disorder, but there was no signed consent form for this psychotropic medication in the resident's file. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the required consent form for Zoloft was not present for the resident. The lack of a signed consent form indicated that the facility failed to ensure the resident's drug regimen was free from unnecessary medications, as required documentation was missing.
Incomplete Medical Records for Medications
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, as identified during a record review. Specifically, two medications prescribed to the resident—Eye Scrubs External Pad and Metoprolol Tartrate 25mg—were found to lack associated diagnoses in the resident's medical record. This omission was confirmed by both the Administrator and the DON during the survey. The deficiency was identified during a review of residents under the care area of unnecessary medications, with the facility census at 57 residents at the time.
Failure to Implement Behavioral Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for residents exhibiting behavioral issues. This deficiency was identified for two residents. Resident #43 was involved in an incident where he was reported to have been touching another resident, leading to the other resident biting him. Despite this incident, the care plan for Resident #43, which was initiated in December 2022 and revised in January 2023, did not include any behavioral focus, goals, or interventions following the incident in April 2024. The facility administrator acknowledged that the care plans did not reflect appropriate behavioral interventions. Similarly, Resident #6 was involved in an incident where she punched another resident, claiming they were thieves. This incident occurred in April 2024, but the care plan for Resident #6, initiated in August 2022 and revised in February 2024, also lacked any behavioral focus, goals, or interventions following the incident. The administrator again acknowledged the deficiency in the care plans, which failed to address the residents' behavioral needs adequately.
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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