Moundsville Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Moundsville, West Virginia.
- Location
- 2200 Floral Street, Moundsville, West Virginia 26041
- CMS Provider Number
- 515067
- Inspections on file
- 21
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Moundsville Healthcare Center during CMS and state inspections, most recent first.
Two residents experienced deficiencies in medical record documentation: one had a care plan that inaccurately reflected dietary preferences regarding egg consumption, while another had inconsistent documentation of incontinence status despite having an indwelling urinary catheter. The DON confirmed the documentation errors and noted that some CNAs were new and required further training.
A resident with a history of exit-seeking behavior eloped from the facility and was found two blocks away. Despite previous warnings and an alarm system, the facility failed to prevent the elopement, placing the resident at risk. The alarm was not responded to promptly, and video evidence was unavailable, contributing to the deficiency.
A resident eloped from the facility through an emergency exit, and the incident was not addressed for 30 minutes. The facility's administrator could not confirm if the alarms were functioning at the time, and video evidence was unavailable. A live test showed the alarm system was operational, but the keypad to disable the alarm was not clearly visible.
Two residents experienced inadequate pain management due to the facility's failure to provide appropriate interventions and medication. One resident with a humerus fracture received only Tylenol, which was ineffective, while another resident's pain was not regularly assessed or treated despite having a prescription for Acetaminophen. Staff interviews confirmed a lack of awareness and proactive management of the residents' pain.
The facility failed to maintain an effective infection prevention program, impacting water management, laundry, and meal services. The water management program lacked documentation to prevent waterborne pathogens, and the laundry area lacked proper separation and ventilation. Additionally, a nurse aide improperly handled a meal tray, indicating a lack of infection control understanding. These issues potentially affected all 120 residents.
A resident's preference for day showers was not consistently honored, leading to dissatisfaction. Despite repeated requests to avoid night showers due to discomfort with wet hair, the facility alternated the schedule to balance shower distribution between shifts, as confirmed by staff interviews.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in communication, nutrition, pain management, and the use of positioning devices. One resident's care plan omitted the use of a necessary communication tool, another experienced significant weight loss without proper notification, and a third used a pommel cushion without an order or care plan documentation.
The facility failed to meet the activity needs of two residents. One resident was not assisted into their wheelchair, preventing participation in group activities, while another remained in bed due to discomfort from a lift sling and lack of a chair. Staff confirmed the absence of necessary equipment and facilitation for group activity participation.
A facility failed to follow professional standards for tube feeding, as a resident's MAR showed inconsistencies in documenting tube feeding bolus administration. The resident had a physician's order for tube feeding if oral intake was less than 50%, but records lacked clear documentation of whether the bolus was given. An LPN confirmed the documentation errors, indicating a deficiency in the facility's practices.
The facility failed to store food safely, with several items in the kitchen's refrigerator and freezer found to be out of date, potentially leading to foodborne illness. The Dietary Manager confirmed the expired items, which included chicken noodle soup, sliced cheese, Parmesan cheese, pepperoni, and tomato sauce. This failure to adhere to the facility's food storage policy could affect more than a limited number of residents.
The facility failed to provide timely and dignified meal service to residents, as observed in several instances. A resident received her meal tray after her roommate, despite her complaints, due to disorganized tray distribution. Another resident was served significantly later than others at her table, and a third resident received her meal much later than her roommate due to incorrect tray placement. Staff interviews confirmed the lack of order in meal service.
A resident was not provided with a geriatric chair for transportation to activities, despite expressing a desire to participate and discomfort with the mechanical lift sling. Staff confirmed the absence of a chair, and there were no orders for one. Additionally, the facility failed to post the Ombudsman's contact information at a level accessible to residents in wheelchairs, as confirmed by observations and the administrator.
A confidentiality breach occurred when an RN left a computer screen displaying resident information unattended in the hallway. The RN, who was administering medication, acknowledged the mistake upon returning to the cart, noting it was an unusual oversight.
A facility failed to ensure an accurate MDS assessment for a resident who had a fall resulting in a fractured hip. The MDS incorrectly indicated no falls since the prior assessment, which was later confirmed as an error by the MDS RN.
A facility failed to invite a resident's representative to care plan conferences, as required. The representative attended only one conference in the past year, shortly after the resident's admission. The DSS confirmed that the task of sending invitations was neglected after the ADON left. A review of sign-in sheets showed the representative attended one out of six conferences.
A resident with a broken shoulder reported severe pain and inadequate pain management at the facility. Despite the absence of a physician's order, an LPN administered Tylenol, which did not alleviate the pain. The resident was informed that additional Tylenol was unavailable for several hours. The DON and Administrator were notified of the medication administration without a proper order.
A resident with a contracture and muscle pain in her left hand did not have a physician-ordered palm guard in place during multiple observations. The care plan required the use of a palm guard, but it was found in the laundry and not returned for two days. The interim DON was unaware of any refusal by the resident to wear the guard, and the TAR inaccurately indicated it was applied. An LPN confirmed the guard was eventually retrieved and placed on the resident.
The facility failed to store insulin in accordance with professional standards, as two medication carts contained vials of Lantus insulin opened for more than 28 days. A resident's insulin vial in the 600 hallway cart was opened on 02/28/24, and another resident's vial in the 300 hallway cart was opened on 02/25/24. Both residents had daily insulin orders, and the product information specifies a 28-day usage period for opened vials.
The facility failed to maintain complete and accurate medical records for two residents. One resident's refusal to wear heel protectors was not documented, despite staff acknowledging the refusal, and the Treatment Administration Record inaccurately showed compliance. Another resident's care plan included PTSD, but this diagnosis was missing from their medical records, as confirmed by the administrator.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the care plan documented by activity staff stated that the resident did not eat meat, fish, eggs, or caffeine due to religious beliefs. However, the dietary order specified a lacto-ovo vegetarian diet, which includes eggs and dairy. The resident's Medical Power of Attorney confirmed that eggs were an important part of the resident's diet, and the Director of Activities acknowledged that the care plan needed updating to accurately reflect the resident's current dietary preferences, which included eggs. For another resident, record review revealed multiple inaccuracies in the documentation of bladder incontinence status. Despite the resident having an indwelling urinary catheter for obstructive uropathy, documentation inconsistently recorded the resident as incontinent on several dates, rather than indicating that continence could not be rated due to the catheter. The Director of Nursing verified the presence of the indwelling catheter and recognized the need for additional training for CNAs, as some were new and had not documented the resident's status correctly.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide a safe environment for a resident, leading to an elopement incident. The resident, who had a history of attempting to exit the building and displaying aggressive behavior, managed to leave the facility unattended. On the day of the incident, the resident was found two blocks away by an off-duty staff member and was subsequently returned to the facility. The resident's behavior included agitation, verbal aggression, and physical threats towards staff, which were documented in the facility's records. The incident occurred despite previous warnings of the resident's intentions to leave the facility. Staff notes indicated that the resident had expressed a desire to 'break out' and had been redirected by staff, but these measures were insufficient to prevent the elopement. The facility's alarm system, which was supposed to alert staff to unauthorized exits, was not responded to in a timely manner, and the administrator could not confirm if the alarms were functioning at the time of the incident. Video evidence of the elopement was unavailable as it was only retained for two weeks. The facility's failure to prevent the resident's elopement placed the resident at risk and resulted in an Immediate Jeopardy situation. The lack of immediate response to the alarm and the inability to provide video evidence of the incident were significant factors in the deficiency. The resident's continued agitation and combative behavior after returning to the facility further highlighted the need for a more effective supervision and intervention strategy to ensure resident safety.
Removal Plan
- The facility completed training with all staff.
- Training included increased behavior/elopement education.
- All staff have the responsibility to notify appropriate team members if they observe an increase or change in residents' behaviors.
- Different departments have different interactions with residents daily and assist with providing the best care possible by ensuring clear communication is had between departments.
- CNA's can create clinical alerts for nursing to review and managers can report in daily meetings.
- It is every staff member's responsibility to investigate the situation if they hear an alarm going off.
- If a door is found to be open, a headcount is to be initiated by each nurse on their respective hall.
- Staff were expected to complete a post-test that included three questions.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate the elopement of a resident, which was identified as a deficiency by surveyors. The incident occurred when the resident exited the facility through the front door via an emergency exit at 7:03 PM and was not noticed until 7:35 PM when an off-duty RN alerted the staff. The facility's administrator could not confirm if the doors were alarmed at the time of the incident and could not provide video evidence as it was only retained for two weeks. The administrator stated that the alarms were functioning properly when tested after the event. During the survey, the surveyors requested a live test of the alarms, which demonstrated that the emergency delayed egress on the door was functioning as designed, with a shrill alarm audible around the door's proximity. A repeater alarm was also audible at the nurse's station, indicating that the alarm system was operational. However, the surveyors noted that the keypad to disable the alarm was not clearly visible from the door, and a staff member was observed rushing to disable the alarm without initially identifying the reason for the alarm.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for Resident #318, who had been experiencing severe pain due to a right humerus fracture since their admission on 03/11/24. Despite the resident's complaints of pain, the facility did not have any orders for non-pharmacological interventions or pain medications other than Tylenol, which was not effective. The resident's pain was not adequately addressed, and there was a lack of proper documentation and follow-up on the resident's pain management needs, as confirmed by interviews with the resident and staff. Resident #75 also experienced inadequate pain management. The resident reported pain in her legs and hand, but her care plan and medical records lacked evidence of regular pain assessments or administration of prescribed pain medication. Although the resident had an order for Acetaminophen, there was no record of it being administered, nor were there any pain assessments documented in her chart. Interviews with staff revealed a lack of awareness and proactive management of the resident's pain. The deficiencies in pain management for both residents highlight a failure in the facility's processes to assess, document, and address pain effectively. The lack of timely and appropriate interventions, as well as the absence of pain assessments and medication administration, contributed to the residents' continued discomfort and unmet care needs. These findings were brought to the attention of the Director of Nursing and the Administrator, who acknowledged the issues identified during the survey.
Inadequate Infection Control in Water, Laundry, and Meal Services
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which is crucial for preventing the development and transmission of communicable diseases, including COVID-19. During a review of the facility's water management program, it was found that documentation was not maintained to prevent the growth of waterborne pathogens. Specifically, the facility lacked a detailed description of the building's water system, including a flow diagram identifying areas where Legionella control measures are necessary. The Maintenance Director confirmed that the facility did not maintain the water management program. Additionally, the facility's laundry services were found to be inadequate in preventing cross-contamination. An observation revealed that there was no sealed separation between the soiled and clean laundry areas, and the air flow vent was not operational, which was confirmed by the Laundry Supervisor. Furthermore, during meal services, a nurse aide was observed placing a tray back on a clean cart after a resident refused the meal, indicating a lack of understanding of proper infection control practices. These deficiencies had the potential to affect all 120 residents in the facility.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor the choices of a resident by not scheduling showers during the resident's preferred time of day. The resident expressed a preference for day showers to avoid going to bed with wet hair, a request that was not consistently honored. Despite the resident's repeated requests and stated preferences, the facility continued to alternate the resident's shower schedule between day and night shifts without providing a clear explanation for the changes. Interviews with staff, including an LPN and a nurse aide, confirmed the resident's dissatisfaction with the shower schedule. The staff acknowledged the resident's preference for day showers but indicated that the schedule was altered to accommodate another resident's request, resulting in an uneven distribution of showers between shifts. This inconsistency in honoring the resident's choice led to the deficiency noted during the survey process.
Deficiencies in Care Planning for Communication, Nutrition, Pain, and Positioning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in communication, nutrition, pain management, and the use of positioning devices. For one resident with hearing difficulties, the care plan did not include the use of a wipe-off board, which was a necessary tool for effective communication. This omission was confirmed by the facility administrator after it was brought to their attention. Another resident experienced a significant weight loss of 14.92% over one month, yet there was no documentation in the medical chart indicating that the physician or the resident's representative had been notified, as required by the care plan. Additionally, this resident reported pain in their legs and hand, but the care plan lacked any pain assessments, which were supposed to be conducted regularly according to the care plan. A third resident was observed using a pommel cushion in their geriatric chair, but there was no order or care plan documentation for this device. A registered nurse confirmed that the cushion had been in use for about a month to prevent the resident from falling out of the chair. The facility administrator acknowledged the absence of an order or care plan for the pommel cushion.
Failure to Facilitate Resident Participation in Activities
Penalty
Summary
The facility failed to provide a program of activities that met the physical, mental, and psychosocial well-being of its residents, specifically affecting two residents. Resident #23 expressed that they were unable to attend activity programs because they were not assisted into their wheelchair. The resident's care plan indicated a preference for group activities, but records showed no participation in such activities for three consecutive months. Additionally, there was no documentation of activity preference interviews in the resident's current medical chart, and the facility administrator acknowledged the absence of group participation records. Resident #93 reported being unable to get out of bed due to discomfort from the mechanical lift sling and the lack of a chair for mobility. Observations confirmed that the resident remained in bed over two days, and interviews with staff revealed that the resident did not have a wheelchair or geriatric chair available. The Director of Rehabilitation confirmed the absence of a chair, stating it was removed because the resident never got up. The Activities Leader also confirmed that activities were only offered in the resident's room, as no one facilitated their participation in group activities.
Deficiency in Tube Feeding Documentation and Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for tube feeding, specifically for a resident who had a physician's order for tube feeding bolus if oral intake was less than 50% of meals. The Medication Administration Record (MAR) for the resident showed inconsistencies in documentation, with check marks indicating tube feeding bolus administration without specifying whether it was actually given. Additionally, there were instances where the resident's meal intake was less than 50%, yet the documentation did not clearly indicate if the tube feeding bolus was administered as required. The Licensed Practical Nurse (LPN) confirmed that the check marks on the MAR were meant to indicate that the meal intake percentage was obtained and tube feeding bolus was administered if necessary. However, the records lacked specific documentation of the amount of tube feeding the resident received each day. The LPN acknowledged that the dinner documentation was incorrect and that there was no record of the actual tube feeding amounts administered, highlighting a deficiency in the facility's documentation practices for tube feeding administration.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, which could potentially lead to foodborne illness affecting more than a limited number of residents. During an initial tour of the facility's kitchen, several items in the dietary walk-in refrigerator and freezer were found to be out of date. Specifically, chicken noodle soup, sliced cheese, and Parmesan cheese in the refrigerator had use-by dates that had passed. Additionally, pepperoni and tomato sauce in the freezer were also out of date, with the pepperoni showing signs of spoilage by being brown in color. The Dietary Manager confirmed that all these items were indeed out of date. The facility's policy on food storage, which references F-812, requires staff to inspect food items upon delivery for safe transport and quality, and to ensure proper storage, labeling, and dating of perishable foods, which was not adhered to in this instance.
Failure to Ensure Timely and Dignified Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal service, as observed in multiple instances. Resident #69 experienced a delay in receiving her meal tray, which was served after her roommate had already been served, despite her vocal complaints. Nurse Aide #63 confirmed that trays were served in no specific order, indicating a lack of organization in meal distribution. Similarly, Resident #100 was served her meal tray significantly later than other residents at the same table, resulting in her being served after others had nearly finished their meals. Nursing Assistant #60 acknowledged that trays were supposed to be served in order by table, but this was not happening due to the kitchen's disorganization. Additionally, Resident #75 received her meal tray much later than her roommate, Resident #23, due to the trays being placed incorrectly on the meal cart. The Dietary Manager and the Administrator both noted previous attempts to address this issue, but the problem persisted.
Failure to Provide Necessary Accommodations and Accessible Ombudsman Information
Penalty
Summary
The facility failed to accommodate the needs of a resident by not providing a geriatric chair for transportation to activities and other needs. The resident expressed discomfort with the mechanical lift sling and a desire to participate in activities like Bingo, but remained in bed over multiple observations. Interviews with staff, including a registered nurse and the Director of Rehabilitation, confirmed the absence of a chair for the resident. The Director of Rehabilitation mentioned that a bariatric geri-chair was previously available but was removed due to the resident not getting up, and there were no current orders for a wheelchair or geriatric chair. Additionally, the facility did not have the Ombudsman's contact information posted at a level accessible to residents in wheelchairs. Observations confirmed that the information was not at eye level for these residents, and the facility administrator acknowledged this issue. The deficiency in posting the Ombudsman's information could potentially affect more than a limited number of residents.
Confidentiality Breach: Unattended Computer Screen
Penalty
Summary
The facility failed to protect the confidentiality of resident records when a computer screen displaying resident information was left unattended in the hallway. This incident occurred at approximately 04:01 PM on 04/02/24, when a Registered Nurse (RN) was administering medication and left the computer screen on. Upon returning, the RN acknowledged the oversight, expressing surprise and noting it was an unusual occurrence for them.
Inaccurate MDS Assessment for Resident with Fall
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for a resident reviewed for falls. The resident had a fall on February 4, 2024, resulting in a fractured right hip. However, the Significant Change/Medicare Five Day MDS Assessment with an Assessment Reference Date of February 16, 2024, incorrectly indicated that the resident had not experienced any falls since the prior assessment. This error was confirmed by the MDS Registered Nurse, who acknowledged that the MDS should have reflected the fall with a major injury.
Failure to Invite Resident Representative to Care Plan Conferences
Penalty
Summary
The facility failed to ensure that the resident and/or their representative was invited to care plan conferences, as required. This deficiency was identified during a random opportunity for discovery in the Long-Term Care Process. Specifically, the representative of a resident reported that they had only attended one care plan conference in the past year, which occurred shortly after the resident's admission to the facility. The Director of Social Services confirmed that the responsibility for sending out invitations to care plan conferences had been neglected after the departure of the Assistant Director of Nursing, who previously managed this task. A review of the care conference meeting sign-in sheets corroborated that the representative had only attended one out of six conferences in the past year.
Medication Administered Without Physician's Order
Penalty
Summary
The facility failed to provide care within acceptable standards by administering medication without a physician's order. This deficiency was identified during a long-term care survey process involving 30 residents, with one resident, identified as Resident #318, being directly affected. Resident #318 reported experiencing severe pain since their arrival at the facility due to a broken shoulder that had not healed over two and a half months. Despite their complaints of pain, the facility only provided Tylenol, which was ineffective, and there were no documented orders for any pain management interventions, including Tylenol. An interview with an LPN revealed that Tylenol was administered to Resident #318 without a physician's order, acknowledging the need to obtain an order for PRN Tylenol. The resident expressed dissatisfaction with the pain management, stating that they were told additional Tylenol was unavailable for several hours after the initial dose. The Director of Nursing and the Administrator were informed of the situation, highlighting the facility's failure to adhere to proper medication administration protocols.
Failure to Ensure Use of Palm Guard for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #8, had a palm guard in place as ordered by the physician to prevent further decrease in range of motion. During multiple observations over several days, it was noted that the resident did not have the palm guard on her left hand, despite having a contracture and experiencing muscle pain in her left hand and shoulder. The care plan for Resident #8 included the use of a palm guard on her left hand, with instructions to remove it only for hygiene purposes. However, the palm guard was not observed on the resident during the surveyor's visits. The interim Director of Nursing (DON) was unaware of the resident's refusal to wear the palm guard and attempted to investigate the situation. It was later discovered that the palm guard was in the laundry, and there was no documentation in the resident's medical record indicating refusal to wear it. The Treatment Administration Record (TAR) inaccurately reflected that the splint was applied on the resident on the days it was missing. An LPN confirmed that the palm guard was in the laundry and was not returned for two days, but it was eventually retrieved and placed on the resident.
Improper Storage of Insulin in Medication Carts
Penalty
Summary
The facility failed to store medications in accordance with professional standards of practice, specifically regarding the storage of insulin. During an inspection, two out of three medication carts were found to contain vials of Lantus (glargine) insulin that had been opened for more than 28 days, which exceeds the recommended usage period. For Resident #65, an opened vial of Lantus insulin was found in the 600 hallway medication cart with an opening date of 02/28/24, confirmed by RN #119. Similarly, for Resident #51, an opened vial of Lantus insulin was found in the 300 hallway medication cart with an opening date of 02/25/24, confirmed by LPN #89. Both residents had physician's orders for daily insulin administration, and the product information for Lantus insulin specifies that opened vials should be used within 28 days.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents. For one resident, there was a physician's order to apply heel protectors while in bed and at rest, every shift, and as needed for pressure relief. However, observations over several days showed the resident was not wearing the heel protectors, and staff confirmed the resident refused to wear them. Despite this, the Treatment Administration Record inaccurately indicated that the resident wore the heel protectors every shift. For another resident, the care plan included a diagnosis of Post-traumatic Stress Disorder (PTSD), but this diagnosis was not documented in the resident's medical records. The administrator acknowledged the missing diagnosis and confirmed that it should have been included in the records. These deficiencies highlight a lack of accurate documentation and record-keeping in the facility.
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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