Montgomery General Elderly Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Montgomery, West Virginia.
- Location
- 501 Adams Street, Montgomery, West Virginia 25136
- CMS Provider Number
- 515152
- Inspections on file
- 18
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Montgomery General Elderly Care during CMS and state inspections, most recent first.
The facility failed to ensure residents could voice grievances freely without fear of reprisal, as observed during a resident council meeting. Only one resident knew how to file a grievance, while others showed signs of apprehension when asked about fear of retaliation, indicating a potential systemic failure in maintaining a supportive environment for grievance reporting.
The facility failed to provide an environment free from abuse for two residents. One resident with a history of dementia and aggressive behaviors was involved in multiple altercations, and the facility lacked effective interventions. Another resident reported verbal abuse from an LPN, with witness statements confirming inappropriate conduct. The facility's investigation was inconclusive, and policies on abuse and neglect were not effectively implemented.
The facility failed to implement its abuse policy, as evidenced by incidents involving a resident with dementia who exhibited aggressive behaviors and another resident who reported verbal abuse by an LPN. The facility's investigation was incomplete, lacking thoroughness and corrective actions, and the behavioral care plan was not resident-centered.
The facility failed to report and investigate allegations of abuse and neglect involving two residents. One resident experienced discomfort and perceived derogatory comments from staff, while another resident with dementia exhibited aggressive behavior towards others. The facility lacked effective interventions and documentation, and specific policies for dementia care were absent.
The facility failed to thoroughly investigate allegations of verbal and physical abuse involving two residents. One resident reported verbal abuse by an LPN, while another resident with dementia was involved in a physical altercation. The investigations were incomplete, with no corrective actions identified, and the facility lacked specific policies for dementia care and behavioral monitoring.
The facility failed to develop comprehensive care plans for several residents, omitting critical diagnoses such as vascular dementia and COPD. Additionally, care plan interventions were not implemented for two residents, leading to escalated behaviors and risk of pressure ulcers. Staff interviews confirmed these deficiencies, with the administrator acknowledging the issues.
The facility failed to provide appropriate care for two residents. One resident consistently refused medications without physician intervention, despite high blood pressure readings. Another resident, with multiple diagnoses, was not offered hospice services despite end-of-life symptoms. The facility lacked documentation and policies for addressing these issues, as confirmed by the DON.
A facility failed to provide adequate pain management for a resident with multiple diagnoses, including dementia and anxiety. The resident's pain was not properly assessed or documented, and non-pharmacological interventions were not attempted or recorded. Despite a change in medication from Tramadol to Roxanol, the facility did not consistently document pain levels or the effectiveness of the medication, as required by their policy. Interviews revealed that pain was only documented for as-needed medications, not scheduled ones, leading to inadequate monitoring and management of the resident's pain.
The facility failed to maintain accurate and complete records for four residents. A resident's POST form was missing a preparer's signature and date, while another's activity record inaccurately showed participation during active dying. A pneumococcal vaccination was not documented in the electronic medical record, and another resident's POST form lacked a healthcare provider's signature, potentially impacting end-of-life care.
A facility failed to notify the State Ombudsman of a resident's discharge to the hospital. During a survey, it was found that a resident was transferred for an extended hospital stay without the required notification being sent. The LSW admitted to not sending the notification, citing a lack of awareness of the requirement.
A facility failed to update a resident's care plan to include hospice-specific interventions and coordination with the hospice provider. The resident, with severe cognitive impairment and receiving hospice care, had an incomplete care plan lacking guidance on end-of-life needs. The DON acknowledged that hospice details were kept separately and not integrated into the facility's documentation, leading to a risk of inconsistent care delivery.
Failure to Uphold Residents' Grievance Rights
Penalty
Summary
The facility failed to uphold residents' rights to voice grievances freely and without fear of reprisal, as required by CMS standards. During a special resident council meeting, attended by the activities coordinator and a surveyor, residents were asked if they understood how to file an official grievance. Only one resident, identified as the council president, responded, indicating the location of the grievance folder, while other residents remained silent, displaying hesitant or reserved body language. When asked if they feared reprisal for filing grievances, multiple residents showed signs of apprehension, such as crossing arms, nodding affirmatively, or verbally confirming a fear of staff retaliation. This reluctance and collective unease suggest that residents may not feel safe or supported in expressing concerns, potentially undermining the efficacy of the facility's grievance process. The observed discomfort and hesitation to voice concerns indicate a potential systemic failure by the facility to maintain an open, supportive environment for grievance reporting.
Failure to Provide Abuse-Free Environment
Penalty
Summary
The facility failed to provide an environment free from abuse for two residents, as evidenced by multiple incidents involving Resident #158 and Resident #15. Resident #158, who has a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was involved in several physical altercations with other residents. The medical records and nursing notes indicate that Resident #158 exhibited aggressive behaviors, such as hitting, grabbing, and yelling at other residents and staff. Despite these behaviors, the facility did not have specific policies and procedures related to dementia care and behavioral monitoring/interventions, and the interventions documented were ineffective in managing the resident's behaviors. Resident #15 reported verbal abuse from an LPN, who allegedly made derogatory comments about the resident's weight and threatened to send her to another facility. The resident, who has a BIMS score indicating moderate impairment, was visibly upset and emotional distress was noted. Witness statements from staff and the resident's roommate confirmed that the LPN was loud and reprimanding, but the facility's investigation was inconclusive due to a lack of witnesses and evidence. The facility's response to the incident was inadequate, as the resident continued to be upset and the care plan interventions were not followed by the LPN. The facility's investigation into these incidents was found to be lacking, with no thorough or complete corrective action identified. The facility's policies on suspected abuse and neglect were not effectively implemented, as evidenced by the lack of documentation and follow-up on the incidents. The facility's failure to address the residents' behaviors and the staff's inappropriate conduct contributed to an environment that was not free from abuse, neglect, and mistreatment.
Failure to Implement Abuse Policy and Incomplete Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedure, as evidenced by incidents involving two residents. Resident #158, who has a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was involved in multiple altercations with other residents. Despite being on medications such as Xanax, Lamictal, Zyprexa, and Mirtazapine, Resident #158 exhibited aggressive behaviors, including hitting, grabbing, and yelling at other residents and staff. The facility's documentation showed that interventions were ineffective, and there was no specific policy or procedure related to dementia care and behavioral monitoring/interventions. Another incident involved Resident #15, who reported verbal abuse by an LPN. The resident, who has a BIMS score indicating moderate impairment, claimed that the LPN made derogatory comments about her weight and threatened to send her to another facility. Witness statements from staff and the resident's roommate were inconclusive, and the facility's investigation did not substantiate the allegations. However, the resident remained visibly upset, indicating a failure to address her emotional distress adequately. The facility's investigation into these incidents was found to be incomplete and lacking thoroughness. There were no corrective actions noted in the follow-up of the investigation involving the two residents. The facility's administrator and social worker acknowledged the deficiencies in the investigation process, including the lack of statements from staff or witnesses and the absence of a resident-centered approach in the behavioral care plan.
Failure to Report and Investigate Abuse and Neglect
Penalty
Summary
The facility failed to report all allegations of abuse and neglect to the appropriate state agencies as required. This deficiency was identified during a long-term care survey, affecting two of the four residents reviewed for abuse. One resident expressed discomfort and pain from being left in a wheelchair during mealtime, and a staff member's comment was perceived as derogatory. The facility administrator acknowledged the incident but had not reported it to the state agency until the survey. Another resident, with a history of hallucinations, dementia, and aggressive behavior, was involved in multiple incidents of physical altercations with other residents and staff. Despite these occurrences, the facility's documentation showed that interventions were ineffective, and there was no evidence of a thorough investigation or corrective action. The facility lacked specific policies and procedures for dementia care and behavioral monitoring, which contributed to the ongoing issues with this resident. The facility's failure to report and investigate these incidents thoroughly was further compounded by inadequate documentation and ineffective interventions. The Director of Nursing acknowledged that the interventions were not resident-centered and that the facility did not provide documentation of any effective measures to ensure the safety of other residents. Additionally, an incident on November 8th was not reported or investigated, highlighting a systemic issue in handling and documenting abuse and neglect allegations.
Inadequate Investigation and Behavioral Management in LTC Facility
Penalty
Summary
The facility failed to conduct a thorough and complete investigation regarding allegations of verbal abuse for one resident and physical abuse for another. In the first case, a resident reported verbal abuse by an LPN, who allegedly made derogatory comments about the resident's weight and threatened to send her to another facility. Despite multiple witness statements and the resident's visible distress, the facility's investigation was deemed inconclusive due to a lack of corroborating witnesses and evidence. The LPN was suspended and later returned to work under a Last Chance Agreement, but the investigation did not substantiate the resident's claims. In the second case, a resident with a history of dementia and behavioral disturbances was involved in a physical altercation with another resident, resulting in bruising. The facility's documentation revealed a pattern of aggressive behavior by the resident, including hitting, kicking, and verbal aggression towards staff and other residents. Despite these ongoing issues, the facility lacked specific policies and procedures for dementia care and behavioral monitoring, and the investigation into the incident was incomplete, with no corrective actions identified. The facility's failure to adequately investigate and address these incidents highlights deficiencies in their handling of abuse allegations and behavioral management. The lack of thorough investigations and effective interventions for residents with behavioral issues contributed to the deficiencies identified by the surveyors.
Care Plan Deficiencies and Implementation Failures
Penalty
Summary
The facility failed to develop comprehensive care plans that included all diagnoses for several residents, leading to deficiencies in care. Resident #54's care plan omitted multiple diagnoses, including vascular dementia, pain, shortness of breath, and chronic kidney disease, among others. Similarly, Resident #15's care plan did not include diagnoses such as constipation, hypothyroidism, and COPD. Additionally, Resident #16's care plan was missing diagnoses like heart failure, anemia, and atrial fibrillation. These omissions were confirmed through record reviews and staff interviews, where it was noted that the care plans lacked specific medical terms and descriptions. Furthermore, the facility failed to implement care plan interventions for Resident #15 and Resident #29. For Resident #15, an intervention to maintain a calm environment during behavioral episodes was not followed, resulting in an escalation of the resident's behavior. In the case of Resident #29, the care plan required the resident to wear moon boots at all times to prevent pressure ulcers, but observations revealed that the resident was not wearing them, and staff were unaware of their location. These failures were acknowledged by the facility's administrator and staff during the survey process.
Failure to Provide Appropriate Care and Hospice Services
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents. Resident #23 consistently refused both AM and PM medications from 05/24 to the present, with no physician intervention since 05/24. Despite being educated on the risks of refusing medications, Resident #23 continued to refuse them, and the care plan only included encouragement and masking the taste of medications. The resident's blood pressure was recorded as high 44 times since 06/01/24, yet no further physician intervention was documented. The Assistant Director of Nursing acknowledged the lack of documentation regarding actions taken for the resident's medication refusal. Resident #158 was involved in a physical altercation with another resident, resulting in bruising. The resident had multiple diagnoses, including hallucinations and vascular dementia, and was on a regimen of medications for pain management. Despite the resident's deteriorating condition and the presence of end-of-life symptoms, the facility failed to offer hospice services. The Director of Nursing confirmed that there was no policy or procedure related to hospice services, and the resident was not informed of the available hospice services, nor was there documentation of a care plan addressing end-of-life care. The deficiencies identified in the report highlight the facility's failure to provide appropriate interventions and care planning for residents refusing medications and those requiring end-of-life care. The lack of physician intervention and the absence of hospice service offerings contributed to the deficiencies noted during the survey process.
Inadequate Pain Management and Documentation
Penalty
Summary
The facility failed to provide adequate pain management for a resident, as evidenced by the lack of a formal pain assessment process and a comprehensive, individualized pain management plan. The resident, who had a history of hallucinations, vascular dementia, Alzheimer's disease, major depressive disorder, delusional disorders, and anxiety, was not properly assessed for pain levels despite exhibiting signs of pain such as yelling out, moaning, and facial grimacing. The facility's policy required regular pain assessments and collaboration between the physician, nursing staff, and the resident or their significant others to develop and reassess the pain management plan, which was not adhered to in this case. The resident was initially prescribed Tramadol for pain, which was not effective, leading to a change in medication to Roxanol. Despite this change, the facility did not document the resident's pain levels or the effectiveness of the medication consistently. The resident's care plan included interventions such as administering Roxanol as ordered, documenting its effectiveness, and implementing non-pharmacological measures like gentle rubbing, massage, and repositioning. However, there was no documentation of non-pharmacological interventions being attempted or their effectiveness. Interviews with the Director of Nursing revealed that the facility only documented pain if the resident was receiving as-needed pain medication, not for scheduled medications. This practice led to a lack of documentation and monitoring of the resident's pain levels and the effectiveness of the pain management plan. The deficiency was further highlighted by the absence of documentation of non-pharmacological interventions, which were part of the resident's care plan.
Incomplete and Inaccurate Resident Records
Penalty
Summary
The facility failed to maintain accurate and complete records for four residents during the survey process. For one resident, the POST form was missing the preparer's signature and date, which was confirmed by the administrator. Another resident's activity participation record inaccurately indicated active participation during a period when the resident was actively dying, a discrepancy that the Activities Director could not explain and was confirmed by the administrator. Additionally, a resident's pneumococcal vaccination was not documented under the immunization tab in the electronic medical record, despite having a signed physician's order and other relevant details recorded elsewhere. The Director of Nursing acknowledged this oversight. Furthermore, another resident's POST form was incomplete, lacking a healthcare provider's signature and date, which was confirmed by the administrator. This incomplete documentation could potentially impact the delivery of end-of-life care for the resident.
Failure to Notify Ombudsman of Hospital Discharge
Penalty
Summary
The facility failed to notify the State Ombudsman of a resident's discharge to the hospital. This deficiency was identified during a Long-Term Care Survey Process, where it was found that one of two residents reviewed for hospitalizations did not have the required notification sent. Specifically, Resident #49 was transferred to the hospital for an extended stay, and upon record review, it was discovered that no notification had been sent to the State Ombudsman. During an interview, the Licensed Social Worker admitted to not sending the notification, stating a lack of awareness of the requirement.
Failure to Integrate Hospice Care into Resident's Care Plan
Penalty
Summary
The facility failed to promptly develop and update a resident's care plan to include hospice-specific interventions and care coordination with the hospice provider. During an annual recertification survey, it was observed that the resident, who was admitted with severe cognitive impairment and was receiving hospice care, had an incomplete care plan. The care plan lacked essential guidance for staff on the resident's end-of-life needs, such as pain management protocols, emotional support resources, and end-of-life preferences. The Director of Nursing acknowledged that hospice coordination details were maintained separately in a binder and not integrated into the facility's care documentation for the resident. The Medication Administration Record (MAR) only included contact information for the hospice provider, without further entries addressing coordinated hospice care. This oversight does not meet the standards established under F657, which require prompt and precise updates to the care plan, creating a risk for inconsistent care delivery and unmet needs.
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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