Minnie Hamilton Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Grantsville, West Virginia.
- Location
- 186 Hospital Drive, Grantsville, West Virginia 26147
- CMS Provider Number
- 51A013
- Inspections on file
- 14
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Minnie Hamilton Health Care during CMS and state inspections, most recent first.
A resident in an LTC facility suffered neglect when staff failed to identify and report a suspicious area on her breast, which was later diagnosed as melanoma. Despite daily care, the area was not documented or followed up on until the resident pointed it out during a dermatology appointment. The DON admitted that some staff noticed the area but did not notify the physician, and the issue was not addressed in QAPI meetings.
A resident's melanoma went unnoticed by facility staff despite regular care, as no documentation or physician notification was made regarding a visible spot on her breast. The issue was only identified during a dermatology appointment, leading to a biopsy and diagnosis.
A resident at high risk for skin breakdown developed pressure ulcers despite having a care plan in place. The resident experienced significant weight loss, and the discontinuation of a nutritional supplement may have contributed to the ulcers. The facility did not conduct a root cause analysis or discuss the issue in Quality Assurance meetings, and no protein levels were checked to ensure adequate nutrition.
The facility failed to implement adverse event monitoring and performance improvement activities, affecting all residents. A resident's melanoma was not documented by staff, and the incident was not reported to state officials. The facility also did not fill a weekend RN position, impacting care quality. The DON prioritized hiring an MDS Coordinator over the RN role and did not monitor quality areas beyond re-hospitalizations.
The facility's QAA committee was found non-compliant due to the absence of the Medical Director or an appropriate designee and the Administrator at meetings. The CNO was improperly serving dual roles, and the Administrator's substitutes lacked authority to make necessary system changes, violating CMS guidelines.
The facility failed to update care plans for two residents following significant changes in their medical conditions. One resident was diagnosed with severe depression with psychotic symptoms, but the care plan was not revised to address this. Another resident developed pressure ulcers, but the care plan did not reflect necessary interventions despite physician orders. The DON acknowledged the care plans lacked a comprehensive, person-centered approach.
The facility's medication error rate was 7.41%, exceeding the acceptable 5%. An LPN administered incorrect water flush amounts for a PEG tube feeding and insulin outside the prescribed time window for two residents.
The facility failed to properly store pans in the kitchen, as observed when three wet pans were stacked together after washing and sanitizing. The Dietary Manager confirmed that the pans should have been dried before storage. This deficiency had the potential to affect more than a minimum number of residents in the facility.
The facility failed to properly clean and disinfect shared glucometers according to the manufacturer's instructions. An LPN used an alcohol pad instead of the recommended germicidal wipes, and the DON acknowledged the facility's non-compliance with its own policy, resulting in a deficiency in infection prevention and control.
A resident's melanoma diagnosis was delayed due to the facility's failure to report and document a visible spot on her breast. Despite staff noticing the area, it was not reported to a physician, violating the facility's neglect policy.
The facility did not accommodate wheelchair-bound residents by placing the Ombudsman information board too high for them to read. This was confirmed by staff interviews, including a Nurse Aide/Activity Director and the DON, who acknowledged the board's inaccessibility.
A resident experienced significant weight loss and developed pressure ulcers while receiving enteral feedings. Despite having a care plan, the facility failed to comprehensively assess the resident using the CMS-specified RAI process. The resident's weight continued to decline, and the DON acknowledged the need for a comprehensive assessment but did not complete it, believing the pressure ulcers were healing.
A facility failed to complete a new PASARR for a resident diagnosed with major depressive disorder, recurrent severe with psychotic symptoms. Despite the resident being admitted with a correct PASARR, the new diagnosis was not reflected in an updated PASARR or care plan. This oversight was confirmed by the DON during the survey.
A resident at high risk for skin breakdown did not have their care plan updated to address new pressure ulcers and significant weight loss. Despite interventions like PEG tube feeding, the care plan was not revised to reflect the resident's changing condition, leading to a deficiency noted by surveyors.
The facility failed to securely store Schedule II-V drugs requiring refrigeration, as observed during a medication administration with an LPN. These controlled drugs were not in a box permanently affixed to the medication refrigerator. The DON acknowledged the issue and was unsure how to resolve it without damaging the refrigerator.
A facility failed to report an alleged neglect incident involving a resident's undiagnosed melanoma to state agencies. Staff did not document or notify a physician about a suspicious area on the resident's breast, which was later diagnosed as melanoma. The Director of Nursing acknowledged the failure to implement the facility's reporting policy, and the incident was not reviewed in quality management meetings.
Neglect in Identifying Resident's Skin Condition
Penalty
Summary
The facility failed to ensure a resident was not neglected, resulting in actual physical harm. A resident had an area on her breast that was not identified by the facility staff, despite being showered and dressed daily. This area was later biopsied and diagnosed as melanoma. The resident and her MPOA attended a dermatology appointment for skin irritations on her face, during which the resident herself pointed out the spot on her breast, leading to the biopsy. The facility's records showed no documentation of the area on the resident's breast prior to this appointment, and the weekly summaries by nursing staff did not mention it. During an interview, the DON acknowledged that some staff had noticed the area and reported it, but no follow-up notification was made to the physician. The area was not identified as a concern in the weekly skin assessments conducted by the facility's nursing staff. The incident had not been discussed or reviewed in the facility's Quality Assurance and Performance Improvement (QAPI) meetings, and no audits were performed to ensure that weekly skin assessments were being conducted properly.
Failure to Identify and Report Skin Condition
Penalty
Summary
The facility failed to provide necessary services to a resident, resulting in physical harm. A resident had an area on her breast that was not identified by the facility staff, despite receiving regular baths and assistance with dressing. The resident and her MPOA attended a dermatology appointment for skin irritations on her face, during which the resident requested the dermatologist to examine a spot on her breast. This led to a biopsy and a diagnosis of melanoma. The facility's records showed no prior documentation or notification to the physician regarding the area on the resident's breast. During an interview, the DON acknowledged that some staff had noticed the area and reported it, but no follow-up action was taken. The weekly summaries conducted by the nursing staff did not identify the area as a concern requiring attention. The lack of documentation and communication resulted in a delay in addressing the resident's condition, which was only brought to the facility's attention after the dermatology appointment.
Failure to Prevent Pressure Ulcers in High-Risk Resident
Penalty
Summary
The facility failed to prevent the development of pressure ulcers in a resident who was at high risk for skin breakdown. The resident was incontinent and dependent on staff for activities of daily living. Despite having a care plan in place to prevent skin impairment, the resident developed pressure ulcers on the coccyx and left foot. The care plan included measures such as weekly skin assessments, monitoring for redness or breakdown, and using moisture barrier cream, but these measures were not effective in preventing the ulcers. The resident experienced significant weight loss over several months, and there was a discontinuation of Prosource, a nutritional supplement, which may have contributed to the development of pressure ulcers. The facility did not conduct a root cause analysis or discuss the issue in their Quality Assurance/Integrated Quality Management meetings. Additionally, no protein, albumin, or prealbumin levels were obtained to ensure the resident was receiving adequate nutrition to maintain healthy skin.
Deficiency in Adverse Event Monitoring and RN Staffing
Penalty
Summary
The facility failed to implement adverse event monitoring and performance improvement program activities, which had the potential to affect all residents. A specific incident involved a resident whose Medical Power of Attorney (MPOA) raised concerns about an area on the resident's breast discovered during a dermatology visit. The staff failed to recognize and document this area, which was later diagnosed as melanoma requiring surgery. The Director of Nursing (DON) and the Director of Quality Assurance (DOQA) acknowledged that the incident was not reported to state officials and was not presented to their Quality Assurance/Integrated Quality Management meeting, despite identifying areas for improvement. Additionally, the facility was approved for a waiver to have a Registered Nurse (RN) on weekends, but the position remained vacant. The Human Resources department and the DON did not make sufficient efforts to recruit for this position, relying primarily on job postings on Indeed.com, which yielded minimal applicants. The DON prioritized hiring a Minimum Data Set (MDS) Coordinator RN over filling the weekend RN position, despite acknowledging that the weekend RN role would provide more direct care and potentially improve the quality of care for residents. The DON also failed to monitor quality of care areas beyond re-hospitalizations, such as urinary tract infections, pressure ulcers, pneumonia, falls, and nutrition declines. Although a Plan Do Check Act (PDCA) plan was in place to monitor these areas, the DON did not report monthly as required and discontinued the plan after six months, even though the weekend RN position remained vacant. This lack of comprehensive monitoring and reporting contributed to the deficiency in ensuring quality care for residents.
Non-compliance in QAA Committee Attendance
Penalty
Summary
The facility failed to maintain a compliant Quality Assessment and Assurance (QAA) committee, as discovered during a Long Term Care survey. The deficiency was identified due to the absence of the Medical Director or an appropriate designee and the Administrator at the QAA meetings. The Director of Nursing (DON) revealed that the Chief Nurse Officer (CNO) was acting as the Medical Director's designee while also serving as the Infection Control Nurse, which is not permissible according to CMS guidelines. The guidelines specify that the Medical Director's designee cannot hold another required role, such as the Infection Control Nurse, which the CNO was fulfilling. Additionally, the facility's Administrator was not attending the QAA meetings, and instead, the Social Worker/System Practice Administrator and the Executive Assistant were attending in their place. However, these individuals did not have the authority to make changes to the facility systems, which is a requirement for the role of the Administrator in these meetings. The DON acknowledged that the attendance of these individuals did not meet the compliance requirements as outlined by CMS guidelines.
Failure to Update Care Plans for Residents with New Diagnoses
Penalty
Summary
The facility failed to update the care plan for two residents following significant changes in their medical conditions. Resident #8 was diagnosed with major depressive disorder, recurrent, severe with psychotic symptoms, but the care plan was not updated to address this new diagnosis. The Director of Nursing confirmed that the care plan had not been revised to include interventions for managing the resident's mental health condition. Resident #11 developed pressure areas, including a pressure ulcer on the left foot and coccyx breakdown, but the care plan was not updated to reflect the necessary interventions for these conditions. Despite physician orders for specific treatments and the use of an air mattress, the care plan remained unchanged. The Director of Nursing acknowledged that the care plan did not reflect a comprehensive, person-centered approach to the resident's care needs.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 7.41% during the Long-Term Survey Process. This deficiency was observed in two out of five residents. For Resident #07, an LPN administered a PEG tube feeding with an incorrect amount of water flush. The physician's order specified 110 ml of water before and after the feeding, totaling 220 ml. However, the LPN administered 420 ml of water, acknowledging the error after being questioned by the surveyor. For Resident #15, the LPN obtained a blood sugar reading at an incorrect time and administered insulin outside the prescribed one-hour window. The order required blood sugar checks before meals and at bedtime, with a sliding scale for insulin administration. The LPN administered 4 units of Novolin R insulin based on a blood sugar reading of 286, but this was done outside the designated time frame, as acknowledged by another LPN.
Improper Storage of Wet Pans in Kitchen
Penalty
Summary
The facility failed to ensure that pans were being stored properly in the kitchen. During an observation, it was noted that three pans, which had been washed and sanitized, were stacked together while still wet. This improper storage practice was confirmed by the Dietary Manager, who acknowledged that the pans should have been dried before being stored. This deficiency was identified during a random observation and had the potential to affect more than a minimum number of residents in the facility, which had a census of 24 at the time of the survey.
Improper Cleaning of Shared Glucometers
Penalty
Summary
The facility failed to ensure the safe cleaning and disinfection of glucometers, which were shared among residents. During an observation, an LPN was seen using an alcohol pad to clean a glucometer after performing a blood glucose test on a resident. The LPN was unsure about the dwell time required for the alcohol pad to be effective. The facility's policy stated that cleaning and maintenance processes should follow the manufacturer's recommendations, which specified the use of Clorox Germicidal Wipes or Super Sani-Cloth Germicidal Disposable Wipes for cleaning and disinfecting the glucometers. Upon further investigation, the Director of Nursing (DON) acknowledged that the facility staff were using alcohol pads instead of the recommended germicidal wipes. The manufacturer's instructions explicitly stated not to use any other cleaning or disinfecting solution besides the specified wipes. The DON admitted that the facility had not been adhering to the policy and procedure for cleaning and disinfecting reusable resident care equipment, leading to a deficiency in infection prevention and control.
Failure to Report and Document Skin Condition Leads to Neglect
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent neglect, which had the potential to affect more than an isolated number of residents. A specific incident involved a resident who had a dermatology appointment for skin irritations on her face, during which a spot on her breast was discovered and diagnosed as melanoma. The resident's MPOA expressed concern that the spot, which was clearly visible and should have been reported and treated, was not mentioned by the facility staff, despite the resident receiving regular baths and assistance with dressing. The investigation revealed that while some staff noticed the area and reported it, there was no documentation or notification made to the physician for follow-up. The Director of Nursing acknowledged that the area on the resident's breast was not identified as an area of concern requiring follow-up during the weekly summaries performed by the facility nursing staff. This lack of documentation and reporting was a violation of the facility's abuse/neglect policy, which mandates that all allegations of neglect be appropriately reported and investigated.
Ombudsman Information Inaccessible to Wheelchair Residents
Penalty
Summary
The facility failed to accommodate the needs of wheelchair-bound residents by not posting the Ombudsman information at an accessible height. During a random observation, it was noted that the Board of Notice for Resident's Rights and Ombudsman information was placed too high for residents in wheelchairs to see and read. This was confirmed by an interview with a Nurse Aide/Activity Director, who acknowledged the issue. Additionally, the Director of Nursing also recognized that the board was positioned too high for residents to view.
Failure to Assess Significant Change in Resident Condition
Penalty
Summary
Resident #11 experienced a significant change in condition, including a notable weight loss while receiving enteral feedings and the development of two pressure ulcers. The resident, who was admitted with diagnoses such as Diabetes Mellitus, Dementia, Depression, Schizophrenia, and lung disease, was at high risk for skin breakdown. Despite having a care plan in place to prevent skin impairment, the resident developed pressure ulcers on the coccyx and left foot. Weekly nursing summaries documented the resident's deteriorating skin condition, but there was no corresponding documentation in the physician's progress notes regarding these skin issues. Treatment orders for the pressure areas were eventually written, but the facility failed to comprehensively assess the resident using the CMS-specified Resident Assessment Instrument (RAI) process. Additionally, the resident's weight was monitored, revealing a consistent decline over several months. Despite being fed via a gastrostomy tube with Glucerna 1.5, the resident's weight continued to decrease. The Registered Dietician noted the resident's weight loss and feeding intolerance but did not make further nutritional recommendations. The Director of Nursing acknowledged the significant change in the resident's condition, which required a comprehensive assessment, but admitted that no significant change was completed on the Minimum Data Set (MDS) because the pressure ulcers were thought to be healing after reintroducing Prosource.
Failure to Update PASARR for New Diagnosis
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for a resident who received a new medical diagnosis of major depressive disorder, recurrent severe with psychotic symptoms. This deficiency was identified during a record review and staff interview, which revealed that the resident was admitted with a correct PASARR. However, after the resident was diagnosed with major depressive disorder, a new PASARR was not completed, and the care plan was not updated accordingly. The Director of Nursing confirmed this oversight during the survey.
Failure to Update Resident Care Plan for Skin Breakdown and Nutritional Needs
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented for a resident, identified as Resident #11, to address their medical, physical, mental, and psychosocial needs. The resident was at high risk for skin breakdown, as noted in their care plan, which included interventions such as assisting with turning and repositioning, conducting weekly skin assessments, and providing incontinence care with moisture barrier cream. However, the care plan was not reviewed or revised to reflect the resident's changing condition, including the development of pressure ulcers and a significant weight loss over six months. The resident's medical records indicated a decline in meal intake, leading to the initiation of a PEG tube feeding regimen. Despite this, the resident experienced skin breakdown, including a pressure ulcer on the coccyx and the left foot, and a decrease in weight. The facility's Director of Nursing acknowledged that the care plan did not reflect a comprehensive approach and had not been updated to include new interventions for the resident's pressure injuries. This lack of timely review and revision of the care plan contributed to the deficiency identified during the survey process.
Deficiency in Secure Storage of Controlled Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, specifically Schedule II-V drugs requiring refrigeration. During a medication administration observation with an LPN, it was noted that these controlled drugs were not stored in a box permanently affixed to the medication refrigerator. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the issue and expressed uncertainty about how to fix it without damaging the refrigerator.
Failure to Report Alleged Neglect and Document Skin Condition
Penalty
Summary
The facility failed to report an alleged violation of neglect to the appropriate state agencies, as required by their policy. This deficiency was identified during a review of a complaint made by the Medical Power of Attorney (MPOA) for a resident. The complaint involved a failure by the facility staff to recognize and document a suspicious area on the resident's breast, which was later diagnosed as melanoma. Despite some staff noticing the area, there was no documentation or notification to the physician for follow-up, and the issue was not identified during the weekly skin assessments conducted by the nursing staff. The Director of Nursing (DON) acknowledged that the incident should have been reported to the state agencies and that the facility's policy on reporting allegations of neglect was not implemented in this case. Additionally, the incident was not discussed or reviewed in the facility's Quality Assurance/Integrated Quality Management meeting, and no audits were performed to ensure compliance with the skin assessment procedures outlined in a letter to the resident's MPOA. The lack of documentation and reporting led to a delay in addressing the resident's medical condition, which required surgical intervention.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
