Morgantown Heights Of Journey
Inspection history, citations, penalties and survey trends for this long-term care facility in Morgantown, West Virginia.
- Location
- 1379 Van Voorhis Rd, Morgantown, West Virginia 26505
- CMS Provider Number
- 515049
- Inspections on file
- 21
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Morgantown Heights Of Journey during CMS and state inspections, most recent first.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to deliver individualized, person-centered care as required.
Surveyors found that the facility did not properly store or label food items in the kitchen and pantry, including unlabeled and undated ice cream and macaroni, in violation of facility policies requiring all foods to be labeled, dated, and stored to prevent cross-contamination. This had the potential to affect all residents.
A resident received a Humalog insulin injection from an LPN in the hallway, rather than in a private area, due to the LPN being behind schedule and challenges with obtaining blood sugar readings from the previous shift. This action failed to honor the resident's right to a dignified experience during care.
A resident was left unable to access the call system while in her room, resulting in her having to yell for help for an extended period until staff responded. The call bell was found out of reach, and an LPN acknowledged the issue, noting she was unaware as a nurse aide had recently been with the resident.
A resident's care plan was found to be incomplete and inaccurate, with missing or generic information in key areas such as pain management, bowel incontinence, communication, and ADL assistance. The care plan did not specify individualized needs or interventions, and included incorrect information about the resident's communication abilities, as confirmed by a corporate RN.
A facility failed to report a suspected abuse incident within the required two-hour timeframe. A resident was found with a large bruise, and although the resident reported staff involvement, they were unable to provide further details due to confusion. The incident was reported 16.5 hours later, contrary to the facility's policy.
A resident did not receive the prescribed antibiotic Zyvox due to its unavailability in the facility's system and a delay in cost approval. The medication was on hold, and the resident missed two doses before it arrived. The resident's son questioned the missed doses and requested a transfer due to the oversight.
A resident did not receive the prescribed antibiotic Zyvox due to a delay in medication approval and delivery, resulting in two missed doses. The medication was on hold due to cost approval requirements, which were not completed in time. The resident's son requested a transfer after discovering the missed doses.
A facility failed to investigate neglect allegations and allowed a nursing assistant to work without required training, placing residents in jeopardy. One resident waited long for incontinence care, while another was left in a precarious position. Additionally, medication errors were not properly addressed, with one resident receiving the wrong medication and another's controlled substance unaccounted for.
A LTC facility failed to protect residents from neglect and improper care. Two residents experienced delayed incontinence care, with staff ignoring call lights and refusing assistance. Another resident was improperly lifted after a fall, contrary to their care plan. The DON was unaware of these issues, indicating a lack of oversight and teamwork among staff.
Two residents experienced inadequate pain management, resulting in prolonged suffering. One resident was not given pain medication despite visible distress and fell from his wheelchair. Another resident expressed constant pain and was not assessed for medication effectiveness, leading to continued discomfort. The facility failed to follow its pain management policy, contributing to the deficiency.
The facility failed to ensure the activities program was directed by a qualified professional, affecting all 82 residents. The Activity Director admitted to lacking certification and planned to start a class in March. The DON confirmed the absence of a certified Activity Professional and noted that the Occupational Therapist had not been involved with the activity department for months.
The facility failed to ensure that the binding arbitration agreement was explained to residents in a manner they could understand. A resident was aware of the agreement but not of the revocation option, another did not remember the agreement initially, and a third stated it was not explained in detail. The Admissions Director admitted to not reviewing the entire document with residents, only providing a copy.
The facility did not ensure nursing staff had the necessary competencies to provide adequate care, potentially affecting all 82 residents. Observations and interviews revealed issues, including late medication passes.
The facility failed to develop and implement appropriate care plans for residents with specific medical needs. A resident with dementia and pain lacked a care plan for these conditions, while another resident with persistent pain also had no care plan. A resident requiring dialysis had incomplete documentation of vital sign checks, and another resident had an erroneous care plan for diabetes mellitus.
The facility failed to update care plans for several residents, resulting in unaddressed needs and preferences. A resident's preference for bed baths was not documented, while another's care plan lacked updates for antibiotic therapy and hospice services. Multiple residents experienced pain without proper documentation or management in their care plans. Additionally, a resident's use of a Foley catheter, G-tube, and supplemental oxygen was not reflected in their care plan, and another resident's dementia and pain were not addressed.
The facility failed to provide an adequate activity program for residents, as evidenced by three cases. A resident expressed dissatisfaction with activities and had limited engagement, with no one-on-one visits documented. Another resident was observed without stimulation and had minimal activity participation, despite a care plan indicating group activity importance. A third resident's participation records showed inconsistencies, with the Activity Director acknowledging a lack of invitations and documentation.
A facility failed to prevent accident hazards by leaving medications unsupervised in a resident's room and allowing two residents to smoke in a non-smoking area. A nurse admitted the resident had no order to self-administer medications, and the DON was unaware of the residents' smoking habits, indicating lapses in protocol adherence.
A resident receiving dialysis through a Permacath access was incorrectly monitored for a thrill and bruit, which are applicable to a fistula access. The physician's orders mistakenly required this monitoring, and nurses documented compliance despite the resident not having a fistula. The ADON confirmed the error.
A facility failed to store and label medications according to professional principles. An LPN was unaware that a Tymlos pen-injector for a resident had been in use beyond the manufacturer's recommended 30-day period. The pen-injector lacked a product insert, leading to a deficiency in medication management.
The facility failed to store food according to professional standards, with open and unlabeled food items found in the kitchen and nourishment rooms. Unsanitary conditions were noted, including an employee's cell phone on a prep table. Temperature logs for nourishment rooms were incomplete, and personal items were improperly stored with residents' food.
The facility failed to maintain accurate medical records for several residents, including incorrect oral assessments, missing physician orders, and incomplete medication dosages. Incomplete POST forms and inaccurate snack documentation were also noted. Additionally, a resident's neuropathy diagnosis was missing, and there were inconsistencies in documenting psychotropic medication side effects.
A long-term care facility was found to have multiple infection control deficiencies. Staff members failed to wear gloves while handling food and administering nasal spray, neglected hand hygiene during wound care, improperly disposed of soiled gloves, and did not follow enhanced barrier precautions for a resident with MRSA. Additionally, a used dining tray was placed on a cart with clean trays, risking contamination.
A deficiency was identified in the facility's call light system, which failed to indicate the location of an activated call light on the annunciator panels. This issue was discovered during a tour when the system was sounding without a corresponding light indicator. A CNA noted that the panel sometimes failed for bathroom call lights. The Administrator and staff worked to locate the source, finding that a resident had partially pulled the call light cord from the wall.
The facility failed to provide a safe, clean, and homelike environment, as evidenced by a soiled glove on a handrail, insufficient clean linens, and unclean dining room chairs. Staff confirmed the glove's presence and linen shortages, while the Housekeeping Manager admitted to a lack of cleaning schedule for the chairs, citing staffing issues.
The facility failed to provide scheduled showers to residents, impacting their personal hygiene. A resident reported not receiving showers as scheduled, with records confirming inconsistencies in shower schedules. Another resident received only one shower on a non-scheduled day, and a third resident reported receiving only one bath after a week of stay. The DON acknowledged the lack of documentation and adherence to shower schedules.
The facility failed to follow professional standards of practice, affecting several residents. A resident experienced delayed urinalysis testing due to incorrect order entry, while another did not receive wound care as ordered. A resident used pain patches without a physician's order, and another did not receive prescribed medications. Additionally, a resident lacked a capacity assessment, and medications for two residents were administered late due to staffing issues.
The facility failed to serve meals at safe and palatable temperatures, affecting all residents receiving nutrition from the kitchen. A resident reported receiving cold food, and a dining observation confirmed that meal temperatures were below the required 135 degrees Fahrenheit. The Dietary Manager acknowledged the deficiency.
A facility failed to inform a resident of their right to formulate an advance directive, as required by policy. The resident, admitted for short-term rehab and cognitively intact, had no documentation of an advance directive or end-of-life care orders. Interviews with the DON and ADON confirmed the oversight, which was identified during an annual survey.
A resident requested nasal spray from an RN while in the hallway, and the RN administered it there, breaching privacy protocols. The resident had an order for Saline Nasal Solution for a dry nose. The Assistant Director of Nursing confirmed that medications should not be administered in the hallway.
The facility failed to report alleged misappropriation of medication involving two residents. One resident received the wrong medication, which was not reported promptly by the DON. Another incident involved a missing hydromorphone tablet signed out without an order, with no documentation of administration. The facility did not conduct thorough investigations or report these incidents to the proper authorities in a timely manner.
A facility failed to ensure an accurate discharge MDS Assessment for a resident who was admitted for short-term rehabilitation and discharged to home. The resident's MDS Assessment incorrectly coded the discharge as 'return anticipated,' despite no evidence suggesting the resident was expected to return. The ADON confirmed the inaccuracy of the MDS Assessment.
A facility failed to accurately complete an MDS assessment for a resident with communication deficits due to a stroke and language barrier. Despite staff acknowledging the resident's struggles and using tools like a tablet for family video calls, the MDS inaccurately reflected clear speech and comprehension.
A resident with a communication deficit due to a stroke and language barrier did not have a baseline care plan addressing these needs within 48 hours of admission. Despite having communication aids, the care plan lacked focus, goals, or interventions for her language issues. Staff interviews confirmed the oversight, highlighting the facility's failure to meet the resident's immediate needs.
The facility failed to provide proper catheter care for two residents. A resident's Foley catheter drainage bag was found touching the floor, and another resident's urinary drainage bag was improperly placed, causing urine to back up in the tubing. An LPN confirmed these deficiencies, highlighting a lack of follow-up checks after hospice care.
A facility failed to account for controlled substances when an RN signed out hydromorphone for a resident without a valid order, and the medication was not documented as administered. The DON was aware of the issue but did not initially report it. An Employee Warning form was completed for the RN, and the incident was later reported as misappropriation of property.
A facility failed to monitor the efficacy of psychotropic medications for a resident prescribed mirtazapine and trazodone for anxiety. Despite a care plan goal to remain free from increased restlessness, there was no documentation of monitoring for anxiety symptoms. This was confirmed by the DON during an interview.
The facility failed to store oxygen tanks safely, as required by their policy. An oxygen tank was found on the bathroom floor in a resident's room, which was acknowledged by an LPN as improper. The facility's policy mandates that all oxygen canisters be secured in a rack or wheeled carrier. The ADON confirmed the unsafe storage.
A facility failed to ensure a resident's drug regimen was reviewed monthly by a licensed pharmacist, missing the review for December 2023. This was confirmed by the ADON during the LTC survey process, highlighting a lapse in compliance with monthly review requirements.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and agreed upon, reflecting a deviation from both clinical directives and person-centered care standards.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards and its own policies, as observed during inspections of the kitchen and pantry. In the kitchen, a chest freezer contained a bucket of vanilla ice cream and two pints of ice cream inside a brown paper bag, all without labels or dates, which was acknowledged by the Dietary Manager. Additionally, in the kitchen pantry, a package of elbow macaroni was found with no label or date. Facility policies require all foods to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross-contamination, as well as for storage areas to be neat and date-marked as appropriate. These deficiencies had the potential to affect all 84 residents in the facility.
Insulin Injection Administered in Hallway Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) administered Humalog insulin to a resident in the hallway, rather than in a private setting. The incident was observed at 12:08 PM, and the LPN confirmed during an interview that the injection was given in the hallway, citing being behind schedule and issues with obtaining blood sugar readings from the night shift. The Corporate Registered Nurse (RN) was notified and confirmed that injections should not be administered in the hallway, indicating a failure to provide a dignified experience for the resident during insulin administration.
Call System Inaccessible to Resident
Penalty
Summary
The facility failed to ensure that the call system was accessible to a resident while in their room. On 07/07/25 at 1:10 PM, a resident was heard repeatedly yelling for help and continued to do so for 25 minutes until staff responded. Upon entering the room, the resident was found sitting in a wheelchair at the end of her bed, with the call bell placed out of her reach on the bed near the pillow. During an interview at 1:35 PM, an LPN confirmed that the call button was not within the resident's reach and stated she was unaware of the situation, as a nurse aide had just been with the resident.
Incomplete and Inaccurate Care Plan Documentation
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident, as evidenced by a review of the resident's care plan documentation. Multiple focus areas within the care plan were found to be incomplete or lacking specific information. For example, the section addressing pain management did not specify the type of pain, its duration, or the resident's preferred method of pain control. Similarly, the focus area for bowel incontinence lacked any further details, and the section on communication problems was left blank, despite the resident not having any communication issues. The goals and interventions listed were generic and did not include individualized or measurable actions. Additionally, the care plan's section on assistance with activities of daily living (ADLs) was incomplete, only listing possible levels of assistance without specifying the resident's actual needs. The deficiencies were confirmed by a corporate RN, who acknowledged that the care plan was both incomplete and contained incorrect information regarding the resident's communication abilities. These findings were based on record review, staff interview, and resident interview during the survey process.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to report an allegation of suspected abuse within the required two-hour timeframe after discovering the occurrence. This deficiency was identified for one of the three residents reviewed for reportable allegations of abuse, neglect, and misappropriation of property. Specifically, a resident was found with a large deep purple bruise of unknown origin on the posterior upper left arm, as noted in a skin assessment. The incident was reported 16.5 hours after it was initially discovered, which is a significant delay beyond the mandated reporting period. The medical records indicated that the resident had a bruise noted by a nurse at 11:15 PM, and the resident had reported to social services that staff had caused the bruising. However, the resident was unable to provide further information due to confusion and a low BIMS score. Despite this, the information was communicated to the administrator. During interviews, the facility's staff acknowledged that suspected abuse allegations should be reported within two hours, as per the facility's policy titled 'Freedom from Abuse and Neglect Policy'.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to follow the physician's order for antibiotics for Resident #73, who had a prescription for Zyvox to be administered twice daily starting on 02/14/24. The medication was not available in the facility's Alixa system when the nurse attempted to administer the morning dose. The nurse reported that LPNs or floor nurses are not authorized to approve medications, and the medication was on hold due to its cost, which required approval from the facility. The Director of Nursing eventually approved the medication, but it did not arrive until the morning of 02/15/24, resulting in the resident missing two doses. The resident's son, upon visiting the facility, questioned the administration of the medication prescribed for a UTI and requested his father be transferred out of the facility due to the missed doses.
Failure to Administer Prescribed Antibiotic
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically Resident #73, who did not receive the antibiotic Zyvox as ordered by the attending physician. The physician had prescribed Zyvox to be administered twice daily starting on 02/14/24. However, during a confidential interview, a nurse revealed that when attempting to administer the morning dose on the prescribed date, the medication was not available in the Alixa system. The nurse explained that LPNs or floor nurses are not authorized to approve medications nor do they receive notifications for medication approvals. Consequently, the medication was on hold due to its cost, which required approval from the facility. The Director of Nursing eventually approved the medication, but it did not arrive at the facility until the morning of 02/15/24, resulting in the resident missing two doses. The delay in medication delivery was due to the cost approval process, which was not completed in time for the initial doses. The resident's son, upon visiting the facility, inquired about the missed doses and requested that his father be transferred out of the facility due to the missed medication, which was prescribed for a urinary tract infection (UTI).
Neglect and Medication Errors in LTC Facility
Penalty
Summary
The facility failed to thoroughly investigate allegations of neglect and allowed a nursing assistant to return to work without completing the required Abuse and Neglect training. This placed two residents in immediate jeopardy, as their needs were not promptly addressed. One resident was observed with their call light on for an extended period, requesting assistance for incontinence care, which was not provided until much later. The Director of Nursing confirmed that residents should not wait that long for care, acknowledging the neglectful nature of the situation. Another resident was found in a precarious position in bed, with a strong smell of urine emanating from the room. Despite the resident's calls for help, staff did not provide assistance until much later. The Director of Nursing expressed surprise at the situation, stating that call lights should not be turned off without addressing the resident's needs and emphasizing the importance of teamwork among staff. Additionally, the facility failed to maintain accurate records and investigate medication distribution for two other residents. One resident reported receiving the wrong medication, which was confirmed by a review of the medication cart. Another resident's controlled substance medication was signed out without documentation of administration, raising concerns about missing medications. The Director of Nursing acknowledged the issues but initially did not report them as required.
Removal Plan
- The allegation of neglect was reported to VPCO and ADON. The allegation was reported to the state survey office, APS and Ombudsman by Social Worker. A thorough investigation was initiated.
- Resident #237: A skin assessment was completed by a nurse. A trauma assessment was completed by Social worker.
- Resident #6: A skin assessment was completed by ADON. A trauma assessment was completed by the Social Worker.
- Current residents have been assessed for any signs and symptoms of abuse/neglect. Those residents with BIMs above 8 were interviewed by the management team for any abuse/neglect concerns. Those residents with BIMs below 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect.
- Abuse/neglect assessments, interviews and questionnaires were reviewed by the Administrator for any indications of abuse/neglect concerns. There were concerns voiced during the interviews and were addressed at time of concern.
- Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator.
- President of Clinical Operations will educate Administrator, DON, ADON, and Social Services on conducting a thorough investigation to include interviewing all potential witnesses.
- All potential witnesses will be interviewed to identify any further potential allegations of abuse or neglect.
- All staff will be re-educated on abuse/neglect. Staff who were unable to attend will be provided with education prior to working their next scheduled shift. Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift.
- Call light audits will be conducted per shift by DON or designee. Residents will be interviewed per day by DON or designee for care concerns/allegations of neglect. Observations for resident needs will be conducted of residents on day shift and night shift. The results of these audits will be reviewed through the QAPI committee.
- A nurse from the regional team or corporate office has been onsite or available by phone and will follow up with facility. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of residents and providing oversight and consultation.
Neglect and Improper Care in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect, as evidenced by multiple incidents observed by surveyors. Resident #6 experienced neglect when staff failed to provide timely incontinence care. Despite the resident's call light being activated, staff members were observed ignoring the call and delaying assistance. The resident expressed frustration over the delay, and the Director of Nursing (DON) confirmed that such delays were neglectful. The resident's care plan indicated a need for frequent repositioning and assistance with toileting, which was not adhered to during the incident. Resident #237 also suffered from neglect due to delayed incontinence care. The resident was observed in a compromised position in bed, with a strong smell of urine and later bowel movement emanating from the room. Despite the resident's repeated calls for help, staff members either ignored the calls or refused to assist, citing that the resident was not their responsibility. The DON expressed surprise at the situation, indicating a lack of awareness of the ongoing neglect and emphasizing the need for teamwork among staff to prevent such occurrences. Resident #331 experienced improper handling after a fall. The resident, who was care planned for falls and required a mechanical lift for transfers, was lifted manually by staff members after falling from a wheelchair. This improper lifting technique was contrary to the resident's care plan and resulted in the resident expressing pain during the process. The incident report for the fall was inaccurately completed, and the resident's Power of Attorney was not notified of the fall, highlighting further deficiencies in communication and adherence to care protocols.
Removal Plan
- The allegation of neglect was reported to VPCO and ADON. The allegation was reported to the state survey office, APS and Ombudsman by Social Worker. A thorough investigation was initiated.
- A skin assessment was completed by a nurse. A trauma assessment was completed by Social worker.
- A skin assessment was completed by ADON. A trauma assessment was completed by the Social Worker.
- Resident #237 was assessed by social worker, with no concerns noted. A thorough investigation was initiated and completed by social worker.
- Resident #6 was assessed by social worker, with no concerns noted. A thorough investigation was initiated and completed by social worker.
- Current residents have been assessed for any signs and symptoms of abuse/neglect. Those residents with BIMs >8 were interviewed by the management team for any abuse/neglect concerns.
- Those residents with BIMs < 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect.
- Abuse/neglect assessments, interviews and questionnaires were reviewed by the Administrator for any indications of abuse/neglect concerns. There were 5 concerns voiced during the interviews and were addressed at time of concern.
- Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator.
- All staff will be re-educated on abuse/neglect by the ADON or designee. This training was performed to facilitate discussion and question and include examples. Staff who were unable to attend will be provided with the education prior to working their next scheduled shift. Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift.
- 5 Call light audits will be conducted per shift by DON or designee. 5 residents will be interviewed per day by DON or designee for care concerns/allegations of neglect.
- Observations for resident needs will be conducted of 5 residents on day shift and 5 residents on night shift. The results of these audits will be reviewed through the QAPI committee.
- A nurse from the regional team or corporate office has been onsite or available by phone and will follow up with facility. The nurses from the regional team or home office assist with investigations, observing staff treatment of residents, performing chart audits and providing oversight and consultation.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, resulting in actual harm. Resident #331 was observed in significant pain, grimacing and writhing in his wheelchair, yet was not administered any pain medication. Instead, a muscle relaxer was given, which was not effective for his pain. The resident subsequently fell from his wheelchair, and despite his continued expressions of pain, no immediate pain relief was provided. It was only after several days and continued complaints of pain that appropriate pain medication, including Tylenol and Tramadol, was ordered and administered. Resident #181 also experienced inadequate pain management. Despite expressing constant pain and requesting a different pain medication, the resident was not assessed for the effectiveness of the pain medication she received. Observations showed her in distress, rocking in her wheelchair and later sitting doubled over on her bed, indicating severe discomfort. The facility's policy required pain to be assessed 30 to 60 minutes after medication administration, but this was not done for Resident #181, leading to prolonged suffering. The facility's failure to adhere to its pain management policy and to assess and treat pain in a timely manner resulted in unnecessary suffering for both residents. The staff's inaction and lack of timely intervention in managing the residents' pain were significant factors contributing to the deficiency. The report highlights the need for adherence to professional standards of practice in pain management to prevent harm to residents.
Lack of Qualified Activity Professional
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, which had the potential to affect all 82 residents residing in the facility. During an observation, it was noted that the activity office lacked documentation of a certification for an activity professional. In an interview, the Activity Director (AD) admitted to not having a certificate and mentioned plans to start a class in March. The AD also stated that the Occupational Therapist was reviewing her work, but this was contradicted by the Director of Nursing (DON), who confirmed that the Occupational Therapist had not been involved with the activity department for several months. The DON acknowledged the absence of a certified Activity Professional.
Failure to Adequately Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was explained to residents and their representatives in a manner they could understand, including in their preferred language. This deficiency was identified through interviews with residents and staff, as well as a review of records. Resident #72 was aware of the arbitration agreement but did not know it could be revoked. Resident #8 did not remember the agreement initially but recognized it upon review, although she was unaware of the revocation option. Resident #500 stated that the agreement was not explained in detail at the time of admission. All three residents had a Brief Interview for Mental Status (BIMS) score of 15, indicating they had the capacity to make medical decisions. The Admissions Director, identified as #33, stated that she informs residents that signing the arbitration agreement means giving up their right to a trial by jury, and disputes would be handled outside the courts. However, she admitted to not reviewing the entire document with residents, only providing them with a copy. This practice led to residents not being fully informed about the arbitration agreement, including their right to revoke it. The facility's failure to adequately explain the arbitration agreement has the potential to affect more than a limited number of residents, as indicated by the facility's census of 82.
Inadequate Nursing Competencies Affecting Resident Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide adequate nursing and related services to residents. This deficiency was identified through observations, record reviews, and interviews with residents and staff. The report highlights that this failure had the potential to affect all 82 residents residing in the facility. Specific findings included issues related to late medication passes.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with specific medical needs, as identified during the Long Term Care Survey Process. Four residents were affected by this deficiency. Resident #23, who has a diagnosis of dementia and is prescribed Percocet for pain, reported that the pain medication was not always effective. However, there was no care plan developed for managing her pain or dementia. Similarly, Resident #181, who also reported persistent pain, did not have a care plan addressing her pain management needs. Resident #40 required dialysis due to end-stage renal disease, and the care plan specified that vital signs should be checked every shift for 24 hours post-dialysis. However, the facility failed to document these checks as required. Additionally, Resident #7 had a care plan for diabetes mellitus, but upon review, it was found that the resident did not have this diagnosis, indicating an error in the care plan. These deficiencies highlight the facility's failure to ensure that care plans are accurately developed and implemented to meet the residents' needs.
Care Plan Deficiencies in Addressing Resident Needs
Penalty
Summary
The facility failed to revise care plans for several residents, leading to deficiencies in addressing their specific needs and preferences. For one resident, the care plan did not reflect their preference for bed baths over showers, despite the resident's frequent refusals of showers. Another resident's care plan was not updated to include a diagnosis for antibiotic therapy, a terminal diagnosis for hospice services, and a change in code status to Do Not Resuscitate. Additionally, a resident with multiple diagnoses, including the use of a Foley catheter, G-tube, and supplemental oxygen, did not have these conditions reflected in their care plan. Further deficiencies were noted in the care plans of residents experiencing pain, where actual pain levels were not documented, and prescribed pain management interventions were not included. One resident's care plan did not account for a right lower extremity drop splint, while another resident's care plan failed to address their pain and insomnia, despite the discontinuation of melatonin. Lastly, a resident with dementia and prescribed pain medication did not have a care plan developed for these conditions, indicating a lack of comprehensive care planning for their needs.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and support the well-being of residents, as evidenced by the cases of three residents. One resident expressed dissatisfaction with the activities offered and was observed spending time alone in his room, engaging in repetitive behaviors. His activity participation records showed limited engagement in out-of-room activities, and there was no documentation of one-on-one visits, despite his care plan indicating a preference for such interactions. The Activity Director acknowledged the lack of documentation and was new to the role. Another resident was observed lying in bed without stimulation and reported spending his days waiting for time to pass. His records indicated minimal participation in activities, with no one-on-one visits documented, despite his care plan highlighting the importance of group activities and his interest in trivia, discussion, reading, and word puzzles. The Activity Director admitted to insufficient documentation. A third resident's records showed inconsistencies in documenting participation in group activities, with several days lacking any recorded activities. The resident's care plan included specific activities of interest, but the Activity Director confirmed that invitations to these activities were not consistently extended or documented.
Medication Mismanagement and Smoking Policy Violation
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by two separate incidents involving residents. In the first incident, a registered nurse left medications unsupervised in a resident's room. The resident was observed going through the pills, and upon questioning, the nurse admitted that the resident did not have an order to self-administer the medications. The Assistant Director of Nursing acknowledged awareness of the issue, indicating a lapse in adherence to medication administration protocols. In the second incident, two residents were found smoking in a non-smoking area outside the facility. The Director of Nursing and the Maintenance Director intervened after being informed by another staff member. The residents were unaware of the facility's non-smoking policy, and one resident admitted to bringing cigarettes and a lighter from home. The Director of Nursing confirmed that the residents had not been offered nicotine patches, as their smoking habits were previously unknown to the staff.
Inappropriate Dialysis Monitoring for Resident
Penalty
Summary
The facility failed to provide dialysis care and services in accordance with professional standards of practice for a resident requiring such services. Resident #40, who received dialysis through a Permacath access in her right chest, was erroneously monitored for a thrill and bruit, which are indicators used for a fistula dialysis access. The physician's orders incorrectly instructed staff to auscultate for a bruit and palpate for a thrill every shift, despite the resident not having a fistula. Nurses documented compliance with these orders in the Medication Administration Records for February and March 2024. The Assistant Director of Nursing confirmed that Resident #40 did not have a fistula access, and therefore, the monitoring for a bruit and thrill was not applicable.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. During an inspection of the North 2 medication cart, a pen-injector containing Tymlos (Abaloparatide) for a resident was found. The pen-injector had a date indicating it was opened beyond the manufacturer's recommended usage period of 30 days. The LPN present during the inspection was unaware of the expiration guideline and there was no product insert available with the pen-injector. This oversight was identified as a deficiency in the facility's medication management practices.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as observed during a survey. Several food items in the kitchen were found to be improperly stored, with open containers of grill spray, cornstarch, baking soda, and various seasonings left exposed to the elements without proper labeling or dating. The Dietary Manager acknowledged these lapses, noting that the items should have been discarded due to the lack of labeling. Additionally, unsanitary conditions were noted, such as an employee's personal cell phone being placed on a serving/prep table, which the Dietary Manager admitted was inappropriate. Further issues were identified in the South and North Nourishment Rooms, where opened food items lacked proper labeling and dating, and expired items were not disposed of. The temperature logs for both nourishment rooms were incomplete, with several days missing recorded temperatures for refrigerators and freezers. The Administrator confirmed these omissions. Additionally, a personal lunch box was found in the South Nourishment Room refrigerator, which was acknowledged by a Nurse Aide as inappropriate storage with residents' food.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, leading to multiple deficiencies. For Resident #58, an oral assessment was found to be incorrect, as it noted the resident was edentulous while the resident was observed with fragments of teeth. Resident #179 had a urinary foley catheter without a diagnosis and lacked a physician's order for gastrostomy tube flushes. Resident #10's medication orders were incomplete, with incorrect dosages listed for Aspirin and Guaifenesin. Resident #236's Physician Orders for Scope of Treatment (POST) form was incomplete, missing critical information such as the last four digits of the social security number and the signature of the person completing the form. Additionally, documentation errors were noted for snacks not delivered to Residents #32, #57, and #7, with records inaccurately indicating that these residents consumed their snacks. Resident #7 also had a missing diagnosis of neuropathy in the medical records, despite being prescribed Gabapentin for the condition. Resident #47's medical records showed inconsistencies in documenting side effects of psychotropic medications, with unexplained entries of 'y' for yes on certain dates without corresponding progress notes. These deficiencies highlight significant lapses in record-keeping and documentation practices within the facility, affecting the accuracy and reliability of resident care records.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies. A nurse aide served a sandwich to a resident without wearing gloves, directly handling the food with bare hands. During wound care for another resident, a licensed practical nurse neglected to perform hand hygiene at several critical points. Additionally, a soiled glove was found on the floor of a resident's room, indicating improper disposal practices. In another instance, staff entered a resident's room without donning the required personal protective equipment, despite a clear sign indicating enhanced barrier precautions due to the resident's MRSA status. Further deficiencies were noted when a registered nurse administered nasal spray to a resident without wearing gloves and failed to sanitize the spray bottle before returning it to the medication cart. Additionally, a licensed practical nurse placed a used dining tray on a cart with clean trays, potentially contaminating them. These incidents demonstrate a pattern of non-compliance with infection control protocols, which could affect multiple residents within the facility.
Deficiency in Call Light System
Penalty
Summary
The facility was found to have a deficiency in its call light system, which failed to adequately allow residents to call for staff assistance. During a tour of the facility, it was observed that the call light system was sounding without any light indicator on the annunciator panels for the North or South Units, making it impossible to identify the location of the activated call light. This issue was noted during a random check and had the potential to affect a limited number of residents, including Resident #237. The deficiency was further highlighted when a Certified Nursing Assistant (CNA) acknowledged that the annunciator panel sometimes failed to work for bathroom call lights. The facility staff, including the Administrator and a Corporate Registered Nurse, were involved in attempting to locate the source of the activated call light. It was eventually discovered that Resident #237 had partially pulled the call light cord from the wall, which contributed to the malfunction. The Administrator was aware of the issue and indicated that a technician would be called to address the problem.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and staff interviews. A soiled glove was found stuck in the handrail at the entrance of a resident's room, which was confirmed by two CNAs who subsequently disposed of it. Additionally, the facility was found to have insufficient clean linens available for residents, with the North Unit linen closet completely empty of towels and washcloths, and the South Unit having a limited supply. A CNA reported difficulties in accessing clean linens when needed, and the Housekeeping Manager confirmed the shortage of clean linens at the time. Furthermore, the main dining room chairs were observed to be unclean, with food stains and particles present on the seats and backs. The Housekeeping Manager admitted that the chairs were only cleaned every two weeks and that there was no established cleaning schedule or record. The last cleaning was reported to have occurred during the week of New Year's Eve, and the manager cited being short-staffed as a reason for the delay in cleaning.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents were receiving the necessary services to maintain good personal hygiene, specifically in providing scheduled showers. Resident #44 reported not always receiving showers as scheduled, and a review of her care plan and shower schedule confirmed inconsistencies. In January 2024, she received only one tub bath, three bed baths, and two showers, with only one occurring on a scheduled day. In February 2024, she received one bed bath and two showers on scheduled days, but by the end of the survey in March 2024, she had not received any showers. The Assistant Director of Nursing confirmed these findings. Resident #58 also experienced a lack of scheduled showers, having only received one shower on a non-scheduled day between February 2, 2024, and March 2, 2024, despite being scheduled for showers twice weekly. The Director of Nursing acknowledged the lack of documentation for refusals. Resident #234, admitted on February 21, 2024, reported receiving only one bath at 3 AM after a week of stay. The care plan indicated a need for assistance with ADLs due to weakness and decreased mobility, with showers scheduled twice weekly. The Director of Nursing confirmed that Resident #234 did not receive the scheduled showers.
Deficiencies in Treatment and Medication Administration
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, affecting several residents. Resident #44 experienced a delay in urinalysis testing due to incorrect entry of physician's orders into the computer system, resulting in tests ordered on two occasions not being performed. Resident #40 did not receive wound care as ordered on multiple dates, with no documentation to confirm the dressing changes were completed. Resident #19 was using over-the-counter pain patches brought by a family member without a physician's order, which was confirmed by the LPN and DON. Resident #7 did not receive several medications as per physician's orders, with no nursing notes explaining the omissions. Additionally, Resident #179 lacked a physician's assessment for capacity to make medical decisions, despite having a BIMS score indicating full mental capacity. The DON acknowledged the absence of a capacity form for this resident. Furthermore, medications for Residents #331 and #64 were administered late due to staffing issues, with a single RN covering an entire hallway. This resulted in significant delays in medication administration, with some medications given several hours past the scheduled time. These deficiencies highlight lapses in following physician orders, documentation, and timely medication administration.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and palatable temperature, as observed during a survey. A resident reported that their food was often cold, citing an instance where Salisbury steak was served cold, prompting them to request an alternative meal. During a dining observation, the noon meal trays were found to be below the required temperature at the point of service. Specifically, the meatballs were at 128 degrees Fahrenheit, vegetables at 117 degrees Fahrenheit, and white rice at 127 degrees Fahrenheit. The Dietary Manager acknowledged that the meals should be at 135 degrees Fahrenheit or above, confirming that the meals were not served at a palatable temperature. This deficiency had the potential to affect all residents receiving nutrition from the facility's kitchen.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform and provide written information to a resident regarding their right to formulate an advance directive. This deficiency was identified during an annual survey when reviewing the medical records of a resident admitted for short-term rehabilitation care. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, yet there was no documentation of an advance directive or any end-of-life care orders in the resident's medical records. Additionally, there were no nursing notes indicating that advance directives had been offered to the resident. Interviews with facility staff, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), confirmed that the advance directive was not offered to the resident upon admission. The facility's policy on advance directives, effective since April 2020, requires that residents be provided with information about their rights to refuse or accept medical treatment and to formulate an advance directive. The policy also mandates that staff document any offer of assistance in establishing advance directives and the resident's decision to accept or decline such assistance. However, this procedure was not followed for the resident in question, leading to the deficiency noted by the surveyors.
Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to ensure privacy during the administration of medication for a resident. On February 27, 2024, at 11:13 PM, a resident expressed the need for nasal spray to a registered nurse (RN) while in the hallway outside their room. The following day, at 12:08 AM, the resident, in a wheelchair, requested the nasal spray from RN #55, who administered it in the hallway. The resident had an order for Saline Nasal Solution 0.9% to be used as needed for a dry nose. During an interview, the Assistant Director of Nursing confirmed that medications, including nasal spray, should not be administered in the hallway, indicating a breach of privacy protocols.
Failure to Report Misappropriation of Medication
Penalty
Summary
The facility failed to report alleged violations related to misappropriation of property and did not report the results of all investigations to the proper authorities within the required time frames. This deficiency involved two residents, one of whom, a resident with the capacity to make medical decisions, reported receiving the wrong medication. The resident was supposed to receive morphine sulphate for pain but was given a pill identified as Finasteride, which he was not prescribed. The resident informed the DON about the incident, but the DON did not verify the medication or report the incident promptly. Another resident was involved in a separate incident where a controlled substance, hydromorphone, was signed out by an RN without a corresponding order, and there was no documentation of its administration. The LPN expressed concerns about missing controlled substances, and the DON acknowledged the issue but initially did not consider it reportable. The hydromorphone was later destroyed, and the DON was informed of the missing tablet by the nursing staff. The facility's failure to report these incidents in a timely manner and to conduct thorough investigations led to the deficiency. The DON and other staff members did not follow proper procedures for medication administration and reporting, resulting in potential misappropriation of medication and lack of accountability for controlled substances.
Inaccurate Discharge MDS Assessment
Penalty
Summary
The facility failed to ensure a complete and accurate discharge Minimum Data Set (MDS) Assessment for a resident who was reviewed for the care area of discharge. The resident was admitted for short-term rehabilitation and discharged to home after a brief stay. A Social Service Progress Note indicated that the resident opted to discharge to home, stating he no longer needed to be in the skilled nursing facility for rehabilitation. However, the combined five-day and discharge MDS Assessment incorrectly coded the resident's discharge as 'Discharge assessment - return anticipated.' The Assistant Director of Nursing confirmed that there was no evidence in the resident's medical records indicating an expectation for the resident to return to the facility, thus confirming the inaccuracy of the MDS Assessment.
Inaccurate MDS Assessment for Resident with Communication Deficits
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident, which was identified during a Long-Term Care Survey. The resident, who had a history of a stroke and primarily spoke Spanish, exhibited communication deficits. During an interview, the resident's daughter confirmed that the resident had issues communicating needs, often responding by shaking her head. Despite these communication challenges, the MDS assessment inaccurately reflected the resident's status, indicating clear speech and comprehension. Interviews with facility staff, including the Director of Nursing (DON), a Nurse Aide (NA), and a Licensed Practical Nurse (LPN), revealed that the resident had communication struggles due to the stroke and language barrier. The staff used various methods to assist with communication, such as books and a tablet for video calls with family members. However, the MDS assessment did not accurately capture these communication difficulties, as acknowledged by the DON during the survey.
Failure to Address Communication Deficit in Resident Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan addressing the communication deficit of Resident #233 within 48 hours of admission. Resident #233, who has communication issues due to a stroke and primarily speaks Spanish, was observed during an interview to rely on her daughter for responses and to communicate by shaking her head. Despite the presence of communication aids like books and a tablet with family pictures for video calls, the care plan initiated on 02/13/24 did not include any focus, goals, or interventions for her language deficit. Interviews with the Director of Nursing (DON), a Nurse Aide (NA), and a Licensed Practical Nurse (LPN) confirmed the absence of a care plan addressing the resident's communication needs. The DON acknowledged the oversight, while the NA and LPN described the resident's communication struggles, noting her reliance on non-verbal cues and family assistance via a tablet for communication. The deficiency was identified during a Long-Term Care Survey, highlighting the facility's failure to meet the resident's immediate communication needs upon admission.
Inadequate Catheter Care for Residents
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters received care in accordance with professional standards. For Resident #179, a urinary Foley catheter drainage bag was observed touching the floor, which was confirmed as inappropriate by an LPN. For Resident #29, a bedside urinary drainage bag was found under the bed with urine backed up in the tubing to the resident's leg. An LPN verified this finding and attributed the improper placement to hospice staff who had recently bathed the resident, indicating a lack of follow-up checks after hospice care.
Failure to Account for Controlled Substances
Penalty
Summary
The facility failed to properly account for controlled substances, specifically hydromorphone, for a resident. An LPN reported that controlled substances were missing, and the Director of Nursing (DON) was aware of the issue. The controlled substance sign-out book showed that an RN signed out hydromorphone for a resident on a date when the medication order had already been discontinued. There was no documentation of the medication being administered to the resident, and the DON acknowledged a medication error occurred when the RN administered the medication without a valid order. The facility did not initially report or investigate the missing medication as a reportable issue. The DON later acknowledged awareness of the missing medication when informed by nursing staff during the destruction of controlled substances. An Employee Warning form was completed for the RN involved, citing the administration of medication without an order and lack of follow-up. The facility eventually reported the incident as misappropriation of property after the surveyor's findings.
Failure to Monitor Efficacy of Psychotropic Medications
Penalty
Summary
The facility failed to monitor the efficacy of psychotropic medications for a resident, which was identified as a deficiency during a survey. The resident, identified as #47, had been prescribed mirtazapine and trazodone for anxiety. Despite having a comprehensive care plan with a goal to remain free from signs and symptoms of increased restlessness, there was no documentation in the resident's medical records indicating that the resident was monitored for signs and symptoms of anxiety. This lack of documentation was confirmed by the Director of Nursing during an interview.
Improper Storage of Oxygen Tanks
Penalty
Summary
The facility failed to ensure the safe storage of oxygen tanks, which is necessary for providing appropriate respiratory care to residents. During an observation, an oxygen tank was found improperly stored on the floor of a bathroom in Room #130, with no resident present. A Licensed Practical Nurse (LPN) acknowledged that the oxygen tank should not have been there and should have been locked up. The facility's policy on oxygen tank storage requires that all pressurized oxygen canisters be secured in a rack or fastened to a wheeled carrier, whether they are full, partially full, or empty. This policy applies to canisters in the oxygen storage location or in use in a resident's room. The Assistant Director of Nursing (ADON) confirmed that the oxygen was not stored safely.
Failure to Conduct Monthly Drug Regimen Review
Penalty
Summary
The facility failed to ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, as required. This deficiency was identified during the Long Term Care Survey Process for one of the five residents reviewed for unnecessary medications. Specifically, the records for a resident revealed that there was no pharmacy review completed for the month of December 2023, which was confirmed during an interview with the Assistant Director of Nursing (ADON). The pharmacy notes for the resident showed that monthly medication regimen reviews (MMR) were conducted in September, October, November 2023, and January, February, and March 2024. However, there was a gap in December 2023, where no review was documented. The ADON confirmed the absence of the December review in the resident's chart, indicating a lapse in the facility's compliance with the requirement for monthly pharmacist reviews.
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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