Mercer Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bluefield, West Virginia.
- Location
- 1275 Southview Drive, Bluefield, West Virginia 24701
- CMS Provider Number
- 515052
- Inspections on file
- 28
- Latest survey
- January 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mercer Healthcare Center during CMS and state inspections, most recent first.
The facility failed to ensure a safe environment for three residents by not adhering to fall prevention protocols. A resident's over-the-bed table was improperly placed, exposing them to potential injury. Another resident's room contained unsafe medical supplies, and a third resident's fall prevention measures were not consistently implemented. The DON confirmed these deficiencies during observations.
A facility failed to monitor the effectiveness of pain medication for a resident, who reported constant pain. The resident had an order for Oxycodone-Acetaminophen to be given every eight hours as needed. However, the medication was administered five times without checking its effectiveness, as confirmed by the DON.
The facility failed to adhere to professional standards for storing and labeling multi-use insulin vials. Inspections revealed that several vials were not dated upon opening and were not discarded after 28 days, as required. This involved multiple residents who were still receiving these medications, and the issue was confirmed by LPNs during the survey process.
The facility failed to provide food in the appropriate consistency for residents requiring modified diets. During a meal service, kielbasa sausage was served without being ground, affecting several residents on mechanical and advanced diets. Additionally, a resident with a right-hand contracture struggled to eat whole pork chops and turkey slices, as their meals were not modified to accommodate their needs.
The facility failed to maintain cleanliness in the A and B hall pantries, with ice machines found unclean and a microwave rusting. The CDM acknowledged the need for cleaning and replacement.
The facility failed to conduct thorough investigations into abuse/neglect allegations, with incomplete resident statements and incorrect documentation. A resident was reported as interviewed despite being hospitalized at the time. The facility has a history of similar deficiencies, with repeated citations for inadequate investigations.
A facility failed to honor a resident's right to receive meal trays in a dignified manner. It was observed that a resident's meal tray was served approximately six minutes after their roommate received theirs. This delay was confirmed in an interview with the Administrator, who acknowledged that the resident should have been served and assisted with eating immediately after the roommate's tray was delivered.
A facility failed to thoroughly investigate an abuse allegation involving a resident. The investigation was incomplete, with undated statements lacking proper documentation and a discrepancy in resident identification. Additionally, the resident was not present during the alleged interview, as they were hospitalized, leading to a deficiency finding.
A facility failed to accurately code a resident's discharge location on the MDS. The resident was transferred to another LTC facility, but the MDS incorrectly indicated a discharge to a short-term hospital. This error was confirmed by the NHA during a survey.
A facility failed to refer a resident with a newly diagnosed major depressive disorder for a level II PASARR review. The diagnosis was added to the resident's electronic medical record, but the last PASARR was completed months earlier, and no referral was made. The DON acknowledged the error during an interview.
The facility failed to implement care plans for two residents. One resident's over-the-bed table was improperly placed on a fall mat, posing a hazard, while another resident, with a history of trauma, was assigned female caregivers despite a care plan specifying same-sex caregivers. The DON acknowledged the issues, noting no alternative interventions for the first resident and a lack of male caregivers for the second.
A facility failed to update a resident's care plan after a three-day intervention of Q one-hour checks for elopement risk. The resident, identified as an elopement risk due to dementia, had interventions in place, but the care plan was not revised after the checks were completed. The DON confirmed the oversight during an interview.
A facility failed to complete an Activity Preference Assessment for a resident within the required seven days post-admission. The assessment was delayed until well after the specified timeframe, as identified during a survey. The DON provided documentation outlining the requirement, and the AD acknowledged the oversight.
The facility failed to follow physician orders for two residents. An LPN administered Vitamin D3 without a specified dosage for a resident, and another resident was given a straw despite an order against it. The DON confirmed the lack of dosage specification, and a Medical Records Worker removed the straw after being alerted. The order for the straw was later changed, and a Speech Therapist confirmed the resident could safely use straws.
A resident with dementia and major depressive disorder exhibited aggressive behaviors, but the facility failed to provide necessary psychiatric consultations or effective interventions. Despite documented behaviors, there were no psychiatric services involved, and the care plan lacked specific strategies to address the resident's needs.
A resident with dementia and major depressive disorder exhibited aggressive behaviors, but the facility failed to provide necessary psychiatric consultations or comprehensive social services. The care plan did not adequately address the resident's psychiatric needs, and interventions were limited to redirection by the LSW.
A resident received Aripiprazole without a current order due to a pharmacy error and an LPN's failure to verify medications against the MAR. The resident had a history of schizoaffective disorder and was previously prescribed Aripiprazole, but the order was to discontinue it. The error was identified when the DON confirmed the absence of a current order.
A resident reported not having upper dentures due to cost and experiencing pain with bottom teeth, making it hard to chew. Despite these issues being noted upon admission, the resident stated that no one had discussed dental coverage or dentures with them, indicating a lack of communication and action from the facility to address dental needs.
A resident was served a lunch tray while asleep, and it remained untouched for nearly an hour. Upon waking, the resident ate the cold food, as confirmed by a nursing assistant who did not reheat the tray before serving.
A resident with a contracture in his dominant hand did not receive a required plate guard during meals, as per physician's orders. This resulted in food spillage on his clothing and bedside table. The resident confirmed the plate guard was only sometimes provided, and a therapist acknowledged its absence.
A facility failed to accurately record a resident's DNR status in the electronic medical record. The resident's POST form indicated a DNR status with Selective Treatments, but the physician orders and dashboard documented CPR. An LPN mentioned using the POST form or dashboard to find lifesaving preferences, but a review showed discrepancies between these records.
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter and did not ensure proper hand hygiene during pressure ulcer dressing changes for another resident. An LPN confirmed the need for EBP, and the DON acknowledged the necessity of hand hygiene between wound sites.
Failure to Maintain Safe Environment and Adhere to Fall Prevention Protocols
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents. For Resident #47, the over-the-bed table was consistently placed on the fall mat beside the bed, exposing the resident to potential injury from the table's metal bottom and wheels in the event of a fall. Despite acknowledgment from an LPN and discussions with the Director of Nursing (DON) and Administrator, no alternative interventions were attempted to make the resident's water more accessible without compromising safety. Resident #56's room contained a bottle of Povidone Iodine Prep Solution on the dresser, which was later found in a drawer with other medical supplies, contrary to safety protocols. The DON confirmed these items should not have been in the resident's room. For Resident #71, the care plan included several fall prevention measures, such as a weighted blanket, hipsters, and fall mats, which were not consistently in place during observations. The DON confirmed the absence of these items, indicating a failure to adhere to the resident's care plan designed to prevent falls.
Failure to Monitor Pain Medication Effectiveness
Penalty
Summary
The facility failed to monitor the effectiveness of pain medications for a resident in accordance with professional standards of practice. This deficiency was identified during a Long-Term Care Survey Process for a resident who reported experiencing constant pain. The resident had an order for Oxycodone-Acetaminophen to be administered every eight hours as needed for pain, starting from November 2024. A review of the Medication Administration Reports for November 2024, December 2024, and January 2025 revealed that the medication was administered five times without subsequent monitoring of its effectiveness. The Director of Nursing confirmed that the effectiveness of the pain medication was not monitored according to the Medication Administration Records.
Failure to Properly Label and Store Insulin Vials
Penalty
Summary
The facility failed to store and label medications in accordance with professional standards of care, specifically concerning multi-use vials of insulin. During an inspection of the A2 and B1 hallway medication carts, it was observed that several vials of insulin, including aspart, Lantus, and Novolog, were not dated when first accessed, and some were not discarded 28 days after opening as required. This was confirmed by the Licensed Practical Nurses (LPNs) present during the inspection. The facility's policy requires that the opened date be recorded on the vial, and the expiration date be determined based on the manufacturer's guidelines, which were not adhered to in these instances. The deficiency involved multiple residents who were still receiving these medications, including residents identified as #83, #85, #80, #62, #51, #61, and #57. The vials lacked packaging inserts, which are necessary to verify the expiration dates, and the handwritten expiration dates on some vials were either illegible or incorrect. This oversight in medication management was identified through random opportunities for discovery during the survey process, indicating a systemic issue with the facility's adherence to medication storage and labeling protocols.
Failure to Provide Food in Appropriate Consistency for Residents
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual dietary needs of residents, as observed during a noontime meal service. Specifically, kielbasa sausage was served to residents on the A unit without being ground, despite the requirement for mechanical and advanced diets. The district food manager discovered the oversight after the meal had been served, and it was confirmed that the dietary manager had not prepared ground kielbasa, mistakenly believing it was not necessary. This affected several residents who required ground meat, as indicated by the Consistency Census Report. Additionally, Resident #37, who has a right-hand contracture and is aphasic, was observed struggling to eat whole pork chops and turkey slices during meal times. The resident's Minimum Data Set indicated the need for assistance due to the contracture, yet the meals were not modified to accommodate this need. The resident was unable to eat the meat served, as confirmed by observations and interviews with the resident and the administrator.
Sanitation Issues in Pantry Equipment
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the A and B hall pantries, specifically concerning the ice machines and a microwave. During an observation, the ice machines in both pantries were found to be unclean, with the grates covered in a white scaly substance and an accumulation of water and a brown slimy substance underneath. The Certified Dietary Manager (CDM) acknowledged the need for cleaning. Additionally, the microwave in the B hall pantry was observed to be rusting, and the CDM agreed that it required replacement. These deficiencies were identified during a facility census of 120 residents.
Repeated Deficiencies in Investigation Process
Penalty
Summary
The facility failed to conduct complete and thorough investigations into allegations of abuse/neglect, as evidenced by a review of a facility-reported incident involving a resident. During the investigation, statements from several residents were found to be incomplete, with missing dates and unclear identification of the staff member who took the statements. Additionally, a statement was incorrectly attributed to one resident but signed by another. Notably, the initial report indicated that the social worker had interviewed the resident involved in the incident, but it was later discovered that the resident was not present in the facility at the time, as they had been sent to the hospital the day before. The facility has a history of being cited for similar deficiencies in past surveys, with three instances of failing to thoroughly investigate allegations noted in previous reports. Despite the administrator's acknowledgment of the ongoing issues with the investigation process and the need for more involvement, the same deficiencies were identified during the current survey. This pattern of repeated citations suggests a lack of effective corrective action and oversight in addressing the quality deficiencies related to investigations.
Failure to Serve Meal Trays in a Dignified Manner
Penalty
Summary
The facility failed to honor a resident's right to receive meal trays in a dignified manner. During the Long-Term Care Survey process, it was observed that a resident's meal tray was served approximately six minutes after their roommate received theirs. This delay was confirmed in an interview with the Administrator, who acknowledged that the resident should have been served and assisted with eating immediately after the roommate's tray was delivered.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. The incident was reported to have occurred at the facility, and the investigation process was found to be incomplete and inconsistent. The facility interviewed several residents who were in similar conditions to the resident involved in the allegation. However, the statements collected from these residents were not properly documented, as they were undated and lacked identification of the employee who took the statements. Additionally, there was a discrepancy in one of the statements, where the name of one resident was at the top of the form, but it was signed by another resident. Furthermore, the initial report indicated that the social worker had interviewed the resident involved in the allegation, but no statement from this resident was found. Upon further investigation, it was revealed that the resident was not present in the facility at the time the social worker claimed to have conducted the interview, as the resident had been sent to the hospital a day prior. The social worker later clarified that the initial report should have stated that he spoke with the resident's representative instead. This lack of thorough investigation and documentation led to the deficiency identified during the survey process.
Inaccurate Discharge Location Coding on MDS
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident's discharge location, as identified during a long-term care survey. Specifically, the Discharge Minimum Data Set (MDS) for a resident was inaccurately coded. The resident's medical record indicated a transfer to another long-term care facility, but the MDS was incorrectly coded to reflect a discharge to a short-term general hospital. This discrepancy was confirmed during an interview with the Nursing Home Administrator, highlighting a failure in accurately documenting the resident's discharge destination.
Failure to Refer Resident for Level II PASARR Review
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed serious mental health disorder for a level II review, as required by the pre-admission screening and resident review (PASARR) program. This deficiency was identified during a record review and staff interviews, where it was found that a major depressive disorder was added to the electronic medical record of a resident on November 4, 2024. However, the last PASARR was completed on June 3, 2024, and no subsequent referral for a level II review was made. During an interview, the Director of Nursing acknowledged the oversight.
Failure to Implement Care Plans for Accident Hazards and Same-Sex Caregivers
Penalty
Summary
The facility failed to implement the care plan for Resident #47 regarding accident hazards in his room. Observations on multiple occasions revealed that the resident's over-the-bed table was placed on the fall mat beside his bed, exposing the metal bottom and wheels, which posed a risk if the resident were to fall out of bed. Despite the care plan's directive to ensure the resident's room was free of potential visible hazards, the table remained on the mat. The LPN acknowledged the table's placement and stated it was usually there because the resident needed to reach his water. The Director of Nursing (DON) confirmed that no alternative fall interventions had been attempted to make the water more accessible without placing the table on the fall mat. The facility also failed to implement the care plan for Resident #99, which specified the need for same-sex caregivers due to the resident's history of physical trauma and risk for impaired psychosocial well-being. A review of the nursing assistant assignment sheets showed that the resident was consistently assigned a female caregiver, contrary to the care plan's intervention. During an interview, the DON admitted that the facility did not have male caregivers available and was unaware of why the care plan included this requirement.
Failure to Revise Care Plan for Elopement Risk
Penalty
Summary
The facility failed to revise the care plan for a resident identified as an elopement risk due to dementia and wandering behaviors. The resident's care plan included interventions such as applying a secure device, assessing for basic needs, and providing diversionary activities. An intervention for Q one-hour checks was initiated for a three-day duration starting on 07/09/24. However, the care plan was not updated after the three-day period, as confirmed by the Director of Nursing (DON) during an interview. The deficiency was discovered during a record review and staff interview conducted on 01/23/25. The DON acknowledged that the care plan should have been revised after the three-day period of Q one-hour checks, but it was not. This oversight was identified as a failure to update the care plan in accordance with the resident's current needs and interventions, as the checks were no longer necessary after the specified duration.
Failure to Timely Complete Activity Preference Assessment
Penalty
Summary
The facility failed to provide an ongoing program of activities to support the needs of each resident, as evidenced by the lack of a timely Activity Preference Assessment for a resident. The resident was admitted on an unspecified date, but the activity preference interview was not completed until November 11, 2024, which was beyond the required seven-day period post-admission. This deficiency was identified during a long-term care survey process. The Director of Nursing provided documentation indicating that the Activity Preference Assessment should be completed within seven days of admission or readmission and then annually. The Activity Director acknowledged that the assessment should have been completed by the seventh day.
Failure to Follow Physician Orders for Medication Dosage and Dietary Restrictions
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident #42, a Licensed Practical Nurse (LPN) administered Vitamin D3 from a floor stock bottle without a specified dosage in the physician's order. The order, written on 01/11/25, instructed to give one tablet by mouth daily for vitamins but did not specify the dosage. This oversight was confirmed by the Director of Nursing on 01/22/25, indicating a lack of clarity in the medication administration process. For Resident #88, a physician's order dated 11/29/24 specified a regular diet with dysphagia advanced texture, thin liquids consistency, double entree portions, and no straws. However, on 01/27/25, the resident was observed with a straw in a Styrofoam cup, contrary to the order. A Medical Records Worker confirmed the discrepancy and removed the straw with the resident's permission. The order was later changed to allow straws, and a Speech Therapist confirmed the resident was safe to use them. These incidents highlight lapses in following physician orders and ensuring accurate communication among staff.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the highest practicable physical, mental, and psychosocial well-being. The resident, who has diagnoses including dementia with mood disturbance, generalized anxiety disorder, and major depressive disorder with psychotic features, exhibited behaviors such as verbal and physical aggression. Despite these behaviors being documented over a period of time, the facility did not have any psychiatric consultations recorded in the resident's medical record, indicating a lack of appropriate psychiatric intervention. Additionally, the care plan for the resident identified risks related to impaired psychosocial well-being and outlined interventions such as using same-sex caregivers and removing clothing slowly. However, there were no social service notes addressing how the facility was assisting the resident with his behaviors and psychiatric issues. Interviews with staff, including the Director of Nursing and a Licensed Social Worker, revealed that the resident had not been seen by psychiatric services since admission, and there were no personal interventions in place to manage his aggressive behavior effectively.
Failure to Provide Medically-Related Social Services for Resident
Penalty
Summary
The facility failed to provide necessary medically-related social services to a resident, identified as Resident #99, to help achieve the highest practicable physical, mental, and psychosocial well-being. Resident #99 has a history of dementia with mood disturbance, anxiety, generalized anxiety disorder, and major depressive disorder with psychotic features. A review of the resident's behavior monitoring and interventions report revealed that the resident exhibited behaviors on 15 days since October 1, 2024, and had 13 additional behavior notes from nursing. Despite these documented behaviors, the resident's medical record lacked any psychiatric consultations. The care plan for Resident #99 identified a risk for impaired psychosocial well-being due to a history of physical trauma and aggressive behaviors. However, the interventions listed, such as using a same-sex caregiver and removing clothing slowly, did not address the resident's psychiatric needs. Interviews with the Director of Nursing and the Licensed Social Worker confirmed that the resident had not been seen by psychiatric services since admission and had no personal interventions for aggressive behavior. The social worker's approach was limited to redirecting the resident to sit down, indicating a lack of comprehensive social services to address the resident's needs.
Medication Error Due to Lack of Verification
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of a medication without a current physician's order. During a medication administration observation, an LPN administered medications to a resident, including Aripiprazole, which was not listed in the resident's current Medication Administration Record (MAR). The resident had a history of being prescribed Aripiprazole for schizoaffective disorder, but an order to gradually reduce and then discontinue the medication had been made previously. Despite this, the pharmacy continued to dispense the medication, and the LPN did not verify the absence of a current order before administration. The error was identified when the Director of Nursing (DON) confirmed that the resident's physician's orders did not include Aripiprazole. The pharmacy acknowledged their mistake in not updating the order to discontinue the medication. However, the LPN's failure to cross-check the medications with the MAR before administration contributed to the error. This oversight had the potential to affect the resident's health, as the medication was administered without a valid order.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that residents were provided with necessary dental services, as evidenced by the case of one resident out of four reviewed for dental services during the Long-Term Care Survey process. The resident expressed during an interview that they did not have upper dentures due to the high cost and were experiencing pain with their bottom teeth, which sometimes made it difficult to chew. A record review indicated that the resident had reported mouth or facial pain and difficulty chewing upon admission. Despite these issues, the resident stated that no one had discussed dental coverage or dentures with them, highlighting a lack of communication and action from the facility to address the resident's dental needs.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable temperatures, as observed during a survey. A resident was served a lunch tray at 12:55 PM while asleep, and the tray was left untouched until 1:50 PM when a nursing assistant entered the room. The nursing assistant stated that trays are usually left for about an hour if not eaten. The resident woke up at 2:10 PM, expressed hunger, and began eating with a butter knife before being given a spoon by the nursing assistant. By 2:30 PM, the resident had eaten most of the food and commented that it was cold. The nursing assistant confirmed that the tray was not reheated before the resident ate it.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide ordered assistive eating devices for a resident, identified as Resident #51, who required a plate guard to assist with eating due to a contracture in his dominant right hand. On two separate occasions, the resident was observed eating without the necessary plate guard, resulting in food on his clothing and bedside table. The resident's physician's orders, dated 01/06/25, specified the need for a plate guard as part of his regular diet with dysphagia advanced texture and thin liquids consistency. Despite these orders, the resident did not receive the plate guard, which he confirmed was only sometimes provided, and acknowledged that it helped him feed himself. A therapist confirmed the absence of the plate guard during the survey process.
Inaccurate DNR Status Recording in Medical Records
Penalty
Summary
The facility failed to accurately record the Do Not Resuscitate (DNR) status of a resident in the electronic medical record. The resident's POST form, which was signed and dated, indicated a DNR status with Selective Treatments. However, the physician orders and the dashboard in the electronic health care record documented CPR instead. During an interview, an LPN stated that she would refer to either the POST form or the dashboard in the medical record to find a resident's lifesaving preferences. A record review revealed a discrepancy between the dashboard and the POST form, indicating a failure to maintain consistent and accurate records of the resident's DNR status.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Specifically, Resident #51, who had an indwelling urinary catheter, did not have the required EBP signage on his door, nor was personal protective equipment (PPE) readily available at his doorway. This oversight was confirmed by Licensed Practical Nurse (LPN) #82, who acknowledged the need for EBP due to the resident's condition but did not provide further information on corrective actions during the survey process. Additionally, the facility failed to ensure proper hand hygiene during pressure ulcer dressing changes for Resident #31. Registered Nurse (RN) #75 was observed performing dressing changes on multiple pressure ulcer sites without performing hand hygiene between glove changes. Despite changing gloves several times, RN #75 did not sanitize her hands when moving between different wound sites, which was acknowledged as necessary by the Director of Nursing (DON). This lack of adherence to hand hygiene protocols during wound care was noted as a deficiency in the facility's infection control practices.
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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