Mountain View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ripley, West Virginia.
- Location
- 107 Miller Drive, Ripley, West Virginia 25271
- CMS Provider Number
- 515065
- Inspections on file
- 17
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Mountain View Care Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not follow menus, failed to provide consistent portion sizes, and made unapproved food substitutions without Registered Dietician input. Residents reported ongoing dissatisfaction with food quality, portion sizes, and lack of communication about menu changes, while posted menus often did not match meals served.
Multiple failures in food service were observed, including a resident being served a meal that had been left uncovered and was cold, with food temperatures measured in the danger zone. Additional concerns were reported about food quality, temperature, and contamination, such as a hair found in a dessert. Residents also voiced ongoing dissatisfaction with food temperature, portion size, and texture.
Staff failed to check the internal temperature of hamburger patties before serving, resulting in undercooked meat being placed on trays for residents. A surveyor intervened to prevent the undercooked food from being served, highlighting a lapse in food safety protocols.
A resident's room was found to have HVAC filters covered in gray dust bunnies, with both the Maintenance Director and Director of Housekeeping confirming the filters had not been cleaned as required.
A resident with significant weight loss was not properly assessed or monitored, as the facility failed to obtain weekly weights per RD and risk management recommendations. The DON confirmed that weights were not completed, and there was no evidence that the physician or responsible party was notified of the resident's ongoing weight loss.
A resident who was ordered a Mechanical Soft texture diet with nectar thickened liquids was instead served a pureed meal, contrary to the physician's order and care plan. Staff confirmed the incorrect meal consistency was delivered without adjustment.
A resident with an order for nectar thickened liquids was served honey thickened liquids during a meal, contrary to their care plan and physician's order. This failure was observed and reported by staff, and confirmed through review of the resident's records and care plan.
Multiple residents requiring mechanical soft or pureed diets were served food items such as whole meatballs, whole pasta, deep-fried French fries, and coleslaw, which did not meet prescribed texture modifications. Some residents also received liquids that were either not thickened or were too thick, contrary to their orders. Staff interviews and observations revealed inconsistent adherence to dietary policies and improper use of thickening agents, resulting in immediate risk to residents.
Several residents experienced significant delays in receiving their meals, with some waiting up to thirty-three minutes after their tablemates had been served, and others repeatedly asking for their food while staff continued to serve other tables. Staff confirmed that meals should have been served together. Additionally, all residents were served on styrofoam bowls and plates because the kitchen ran out of standard dining ware, as verified by dietary staff. These actions resulted in a failure to provide a dignified dining experience.
The facility did not promptly or effectively address repeated Resident Council concerns about meal service, including issues with drink timing, menu substitutions, and unfulfilled food preferences. Observations confirmed that drinks were served too early, meals did not match the posted menu, and food meetings with kitchen management were inconsistently held. Staff acknowledged the ongoing nature of these problems.
The facility did not ensure that survey results were posted in a location easily accessible to residents. During interviews, residents reported not knowing they could access the survey findings, and staff confirmed the results book was kept behind the front desk rather than in a public area.
A resident's wheelchair was repeatedly observed to be dirty with dried food and liquids over several days, and staff confirmed it had not been cleaned. Additionally, the kitchen ceiling, exhaust fan, and shower room ceiling with peeling paint were not cleaned. The administrator stated there was no policy or schedule for cleaning wheelchairs or facility areas.
A treatment cart was left unlocked and unattended in a hallway with residents nearby, and a resident at risk for elopement was present while the wanderguard exit system was not functioning properly. Both deficiencies were confirmed by staff and documentation.
The facility did not maintain adequate nursing staff levels, resulting in prolonged call light response times and residents being left in bed due to lack of assistance. Multiple residents and staff reported frequent understaffing, especially on weekends and night shifts, which led to unmet care needs and incomplete tasks.
The facility did not consistently provide residents with the correct food portions, types, and consistencies as ordered, including failing to serve double portions to a resident with a history of weight loss and not following posted menus. Staff and residents reported frequent menu substitutions, insufficient food, and missing items, with dietary staff confirming errors in meal preparation and serving sizes.
Surveyors found that food was not consistently held or served at safe and palatable temperatures, with hot foods below 135°F and cold foods above 41°F. Dietary staff confirmed temperature discrepancies, and a resident reported food was not hot. Review of food temperature logs revealed missing and disorganized records, indicating a lack of consistent monitoring and documentation.
Several residents were served foods they had specifically listed as dislikes or 'do not serve' items, such as green vegetables, broccoli, gravy, and pound cake with strawberry topping. Staff and administration confirmed these errors, which were due to failures in updating or following dietary profiles and meal tickets, and appropriate food substitutes of equal value were not provided.
Two residents with physician orders for adaptive eating equipment, including a plateguard and grip bowl, were repeatedly served meals without the required items. One resident, at nutritional risk, did not receive a plateguard as ordered, and the equipment was not listed on the meal ticket. Another resident with dysphagia struggled to eat without a grip bowl and plateguard, and staff only provided the equipment after being notified of the omission, despite the orders being present on the meal ticket.
Surveyors identified multiple deficiencies in food storage, labeling, and sanitation, including unsealed and undated pantry and refrigerated items, improper utensil storage, and unclean kitchen equipment. Staff were also observed not following required hygiene practices, such as wearing beard coverings, and food preparation areas were found soiled.
Surveyors observed that trash dumpsters were left open, overflowing, and surrounded by garbage including paper and gloves, with confirmation from the DMIT. Trash collection was reported to occur three times weekly, but garbage was not properly contained or disposed of, potentially affecting multiple residents.
Surveyors identified failures in accurate medical recordkeeping, including incorrect documentation of blood pressure readings for a resident with an AV fistula, discrepancies between physician orders and care plans for a resident on NPO status, and missing daily nutrition intake records for another resident. These issues were confirmed by facility leadership.
A facility did not obtain a statement from a cognitively intact resident during an investigation into alleged staff-to-resident abuse, despite interviewing staff present at the time. The resident later confirmed that no facility staff had asked her about the incident.
Two residents had inaccurate MDS assessments: one was incorrectly coded for trunk restraint use without supporting physician orders or care plan documentation, and another's diagnosis of depression was omitted from the MDS despite a documented history and ongoing treatment with trazodone. Facility staff acknowledged these errors during the survey.
Two residents did not have their individualized needs addressed in their care plans: one was not provided briefs in bed or had the use of a one-piece outfit documented, and another did not receive a required plateguard with meals due to a breakdown in communication between nursing and dietary staff.
A resident's care plan was not revised after the order for a Kennedy cup, an adaptive drinking device, was not renewed following a hospital stay. Although the care plan still indicated the use of the Kennedy cup at meals, the resident was not provided with one, and staff confirmed the care plan had not been updated to reflect the discontinued order.
A nurse aide did not receive a required annual performance evaluation, with the last review on file being outdated. This lapse was confirmed by the RDO during a review of staffing records, potentially impacting a significant number of residents.
A Novolog insulin pen was found in a medication cart with an opening date exceeding the 28-day usage period recommended by the manufacturer and pharmacy label. An LPN confirmed the insulin was still being used for a resident despite being expired, and records showed the resident received doses after the expiration period.
The facility did not complete required laboratory tests as ordered by physicians for two residents. One resident did not receive a liver panel as part of scheduled labs, and another did not have a scheduled HgbA1C test performed. The DON confirmed that these tests were not completed as ordered.
Dirty clothes were observed lying on the bathroom floor in a resident's room, with a housekeeping aide stating that the resident places her clothes there for aides to pick up. An MDS nurse confirmed the presence of the soiled clothing, indicating a failure to maintain proper infection prevention and control practices.
Failure to Follow Menus and Ensure Consistent Meal Service
Penalty
Summary
The facility failed to ensure that menus met residents' nutritional needs, were prepared in advance, and were followed as required. Staff interviews and observations revealed that food service staff did not use proper serving sizes or utensils, with cooks admitting to guessing portion sizes and serving inconsistent amounts of food. Production sheets and serving size documentation were not available when requested by surveyors, and serving scoops were not filled completely. During meal service, some residents received less than the intended portion of chicken, and the kitchen ran out of key menu items such as chicken and broccoli, leading to unapproved substitutions without Registered Dietician consultation. Additionally, the current menu was not posted, and residents were not informed of menu changes, with posted menus often not matching what was served. Resident Council meeting minutes over several months documented ongoing concerns about food quality, portion sizes, menu substitutions, and lack of communication regarding menu changes. Residents reported not receiving meals as listed on the menu, dissatisfaction with food temperature and toughness, and unfulfilled scheduled events such as cookouts. The facility's own policies required that all substitutions be noted and menus be updated, but these procedures were not followed, as evidenced by both staff and resident reports and direct surveyor observation.
Failure to Provide Palatable and Safe-Temperature Food
Penalty
Summary
The facility failed to ensure that food and drink served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. One resident received a meal tray that had been left uncovered in the main dining room for approximately 40 minutes before consumption. The food was not reheated or cut up by staff, and the resident reported that it was cold and difficult to chew. Temperature checks of the meal items revealed that all were within the danger zone, as defined by the facility's own policy, with none of the items meeting safe serving temperatures. Additionally, an anonymous interview indicated that food was frequently overcooked, of poor quality, and often served cold, including coffee that was not hot enough to dissolve creamer. Further observations included a tray provided for surveyors, where the garlic bread was found to be dry and crunchy, and a hair was discovered baked into the chocolate cake. The Regional Dietary Manager confirmed the presence of the hair. Resident Council Meeting minutes also documented ongoing concerns from residents regarding food temperature, portion size, and the toughness of food. These findings demonstrate multiple failures in food service practices, affecting the quality and safety of meals provided to residents.
Failure to Ensure Safe Food Preparation and Service
Penalty
Summary
The facility failed to ensure that food was prepared and served in a manner that prevents foodborne illness. On the day in question, after running out of chicken, hamburger patties were substituted and cooked by staff. The cook and another staff member did not check the internal temperature of the hamburger patties before placing them on buns and preparing them for service to residents. A state surveyor intervened and requested that the temperatures of two patties be checked; the readings were 149 and 151 degrees Fahrenheit, both below the recommended safe temperature for ground beef. Despite this, a staff member instructed that the undercooked hamburgers be placed on trays to be served to residents, but the surveyor intervened again and the hamburgers were removed from service. These actions demonstrate a failure to follow proper food safety protocols, specifically regarding the cooking and serving of ground beef at safe temperatures, and the lack of temperature monitoring prior to serving food to residents.
Failure to Maintain Clean HVAC Filters
Penalty
Summary
The facility failed to ensure that the heating, ventilation, and air conditioning (HVAC) filter in one of six units observed on A Hall was free of debris. During an observation in room 126-2, both HVAC filters were found to be covered in gray dust bunnies. The Maintenance Director confirmed the presence of debris on the filters and stated that the Housekeeping Department was responsible for cleaning them on a weekly basis. The Director of Housekeeping also confirmed that both filters needed cleaning due to the accumulation of gray dust bunnies.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to assess and review significant weight loss for a resident, as well as to obtain weekly weights as recommended by the Registered Dietician (RD) and risk management. The resident experienced notable weight loss over several months, with documented losses of 8 pounds (5.6%) in one month, 12.6 pounds (8.5%) over three months, and 26 pounds (16%) over six months. Despite the RD's recommendation for double portions and regular weight checks every four weeks, the facility did not complete the required weekly weights. The Director of Nursing (DON) confirmed that the weights were not performed, stating that weekly weights are discontinued when a resident is considered stable. Additionally, there was no evidence that the physician or responsible party was notified of the significant weight loss.
Failure to Provide Physician-Ordered Diet Consistency
Penalty
Summary
The facility failed to provide food in the form ordered by the physician for a resident who required a Mechanical Soft texture diet with nectar thickened liquids. Instead, the resident was served a pureed lunch meal, which did not match the prescribed diet. The resident's care plan also indicated the need for a Regular Diet, Mechanical Soft texture, and Nectar-like fluids. Staff confirmed that the meal provided was of pureed consistency and that it was delivered to the dining room without any changes, despite the dietary order specifying otherwise.
Failure to Provide Prescribed Liquid Consistency
Penalty
Summary
A deficiency occurred when a resident with a physician's order for a puree diet and nectar consistency liquids was provided with honey thickened liquids instead of the ordered nectar consistency. The resident's care plan specified a regular diet with puree texture and nectar thickened liquids, and the facility's policy required that dietary cards and care plans accurately reflect the required liquid consistency. Despite these orders and policies, the resident was served honey thickened liquids during a lunch meal, as observed and reported by staff. The discrepancy was confirmed through record review and discussion with the Director of Nursing, indicating a failure to provide drinks consistent with the resident's needs and prescribed diet order.
Failure to Provide Properly Prepared Modified Diets and Liquids
Penalty
Summary
The facility failed to provide food and beverages in the appropriate form and consistency as ordered for residents requiring mechanical soft or pureed diets. Multiple residents with physician-ordered mechanical soft diets were observed being served whole meatballs, whole penne pasta, and deep-fried French fries, all of which did not meet the required texture modifications. Residents were seen having difficulty cutting their food due to the use of plastic utensils, and some consumed food items that were not properly chopped or ground as per facility policy and menu extensions. Additionally, residents were served ground meat without the required gravy, resulting in food that was not moist as specified in the dietary guidelines. Further deficiencies were observed in the preparation and serving of thickened liquids. Residents with orders for nectar-thickened liquids were given non-thickened or overly thickened beverages, with staff acknowledging errors in the use of thickening agents and measuring techniques. The facility's dietary and nursing staff demonstrated inconsistent knowledge and application of proper food and liquid modifications, as evidenced by staff interviews and direct observations during meal service. The use of incorrect thickening products and improper preparation of thickened liquids contributed to residents receiving beverages that did not match their prescribed consistency. Additional incidents included a resident on a pureed diet being served a mechanical soft meal with coleslaw, and other residents on mechanical soft diets being served coleslaw instead of the appropriate vegetable. These errors were confirmed by staff and were not in accordance with the facility's menu extensions and dietary policies. The cumulative effect of these failures created an immediate risk of choking and adverse outcomes for residents requiring modified diets.
Failure to Provide Dignified Dining Experience Due to Meal Delays and Inadequate Dining Ware
Penalty
Summary
The facility failed to ensure a dignified dining experience for multiple residents, as evidenced by significant delays in meal service and the use of inappropriate dining ware. One resident was left waiting for their meal while others at the same table were served and assisted, only receiving their tray after the delay was brought to the attention of the Director of Activities. Another resident experienced a delay of thirty-three minutes before being served, after all other residents had already left the dining room. Additionally, a third resident waited eighteen minutes after their tablemate was served, repeatedly asking about their food while staff continued to serve other tables first. These delays were confirmed by staff interviews, including the Director of Activities and an LPN Unit Manager, who acknowledged that the residents should have received their meals in a timely manner alongside their tablemates. Further observations revealed that residents were served meals on styrofoam bowls and plates due to the kitchen running out of standard dining ware. This was confirmed by both a dietary aide and a dietary manager, who stated that the kitchen had run out of plates and bowls for the meal service. The use of disposable dining ware and the delays in meal service contributed to a lack of dignity in the dining experience for the affected residents.
Failure to Address Resident Council Meal Service Concerns
Penalty
Summary
The facility failed to act promptly and effectively upon grievances and concerns raised by the Resident Council regarding meal service. Resident Council meeting minutes and concern forms documented repeated issues, including drinks being served before meal trays arrived, meals being repeated too frequently, meal tickets not reflecting residents' preferences, and discrepancies between the posted menu and the food served. An ad-hoc Quality Assurance meeting was held in response, but the actions taken did not directly address the specific concerns raised by the Resident Council. Observations during meal service confirmed that drinks were distributed well before meals, resulting in residents having empty drinks by the time their food arrived. Additionally, there were instances where the kitchen ran out of menu items, and residents did not receive the food listed on the menu. Further interviews and observations revealed ongoing dissatisfaction among residents, with repeated complaints about cold drinks, lack of menu alternatives, and insufficient food quantities. The Resident Council also noted that scheduled food meetings with kitchen management were not consistently held as promised. Staff interviews confirmed awareness of the ongoing issues and acknowledged that the problems persisted despite attempts to address them. The failure to resolve these concerns demonstrates a lack of prompt and effective response to resident grievances, as required by regulations.
Survey Results Not Easily Accessible to Residents
Penalty
Summary
The facility failed to make the results of the last standard survey easily accessible to residents. During a Resident Council meeting, residents collectively stated they were unaware that they had access to the findings from the last standard survey. Upon observation and interview, the survey results book was found behind the front desk rather than in a location easily accessible to residents. The Administrator acknowledged that the book was not in its intended place and instructed that it should remain on the desk. The Receptionist confirmed that the book had always been kept behind the desk during their three months of employment.
Failure to Maintain Clean and Sanitary Resident Equipment and Facility Areas
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment by not cleaning and sanitizing a resident's wheelchair, as well as neglecting to clean the kitchen ceiling, exhaust fan, and the shower room's ceiling and peeling paint. The resident's wheelchair was observed multiple times over several days with a dirty footboard containing dried food-like substances and liquids. Staff, including an LPN, confirmed that the wheelchair remained uncleaned during this period. Additionally, the facility administrator acknowledged that there was no policy, procedure, or cleaning schedule in place for wheelchairs or for the facility overall. These deficiencies were identified through direct observation and staff interviews, and the lack of cleaning and sanitation practices had the potential to affect more than a limited number of residents in the facility.
Failure to Prevent Accident Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards and did not provide adequate supervision to prevent accidents. An unattended and unlocked treatment cart was observed in the hallway near the conference room, with no staff present and residents nearby, creating an accident hazard. Additionally, a resident assessed as an elopement risk and lacking capacity, with a BIMS score of 3 and a wanderguard bracelet in place, experienced a malfunction of the wanderguard system on the exit door in the A Hallway. The system was not functioning properly during the observation period, despite the resident's documented risk for elopement. These deficiencies were confirmed by staff interviews and record reviews.
Insufficient Nursing Staff Leading to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by record review, resident interviews, and staff interviews. Payroll Based Journal (PBJ) data indicated excessively low weekend staffing over a three-month period. Multiple residents reported significant delays in call light response, with some waiting from 30 minutes to several hours for assistance. Residents also described instances where they were left in bed due to lack of available staff, particularly on weekends and during meal times. The Resident Council collectively expressed concerns about prolonged wait times and insufficient help, especially during busy periods. Staff interviews corroborated these concerns, with nursing aides and other employees reporting frequent understaffing, especially on weekends and night shifts. Staff described being left alone on units for extended periods, being unable to complete assigned tasks, and having to leave residents in bed due to insufficient staff to safely operate lifts. Employees also noted that call-ins were not consistently covered, leading to ongoing staffing shortages and unmet resident care needs.
Failure to Provide Prescribed Diets and Follow Menus
Penalty
Summary
The facility failed to ensure that residents received food in the correct amount, type, and consistency as ordered, resulting in multiple instances where dietary needs were not met. One resident with a history of significant weight loss and a care plan specifying double portions of pureed, nectar-thick meals was observed receiving only a single portion, despite both staff and dietary manager confirming the error. The resident's care plan and diet order clearly indicated the need for double portions at all meals, but this was not followed. Additionally, pureed diets did not receive the appropriate vegetables as listed on the menu, with substitutions such as V-8 juice being provided instead of spinach, and inconsistencies in serving sizes were noted by both dietary staff and the registered dietician. Further observations and interviews revealed that menus were not consistently followed, with frequent substitutions and omissions of menu items, such as vegetables and pureed fruits, and reports of insufficient food being served. Residents and family members reported repeated issues with meal portions, menu discrepancies, and the use of plasticware. Staff confirmed running out of food, leading to improvised meals and sandwiches being served. These failures were confirmed through staff interviews, resident council concerns, and direct observation, affecting more than a limited number of residents.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were held and served at safe and palatable temperatures, as required by their own policy and procedure. Observations revealed that hot food items such as steak, French fries, spinach, and pureed meat were served at temperatures below the required 135 degrees Fahrenheit. Additionally, broccoli was found to be held at 101.2 degrees Fahrenheit, and salad at 54.5 degrees Fahrenheit, both outside the acceptable temperature ranges. These findings were confirmed by dietary staff, who acknowledged the temperature discrepancies. A resident also reported that the food was not hot while eating lunch in the dining room. A review of food temperature logs showed significant gaps in documentation, with missing records for several meals on multiple dates. The dietary manager and aides were unable to provide complete and organized temperature logs when requested by the surveyor, and some logs provided were outdated. The administrator confirmed the disorganization and inability to locate the required logs, further evidencing the facility's failure to consistently monitor and document food temperatures as per policy.
Failure to Honor Resident Food Preferences and Provide Appropriate Substitutes
Penalty
Summary
Surveyors found that the facility failed to honor residents' documented food dislikes and did not provide appropriate food substitutes of equal value. Multiple residents were repeatedly served foods they had specifically listed as dislikes or 'do not serve' items on their dietary profiles and meal tickets. For example, one resident who disliked all green vegetables was served broccoli, Brussels sprouts, and buttered spinach on several occasions, despite clear documentation and staff confirmation that these items should not have been provided. Another resident was served broccoli florets, which was listed as a 'do not serve' item, and this was confirmed by staff as an error. Additionally, a resident who disliked gravy was served Salisbury steak with mushroom gravy, and the dietary profile reflecting this dislike was incomplete, resulting in the error not being communicated to dietary staff. Another resident was served pound cake with strawberry topping, which was also listed as a dislike on the meal ticket. In each case, staff and administration confirmed that the residents should not have received these items, and the errors were attributed to failures in updating or following dietary profiles and meal tickets.
Failure to Provide Ordered Adaptive Eating Equipment During Meals
Penalty
Summary
The facility failed to provide ordered adaptive eating equipment to two residents during multiple meal services. One resident had a physician's order and care plan intervention for a plateguard with meals due to nutritional risk and underweight BMI, but was repeatedly served meals without the required plateguard. This omission was observed during several meal services, and it was confirmed that the adaptive equipment was not listed on the resident's meal ticket. The Registered Dietitian explained that the process for ensuring adaptive equipment is provided relies on nursing staff completing a communication form, which had not been done in this case. Another resident, who had a physician's order for a grip bowl and plateguard due to dysphagia following a cerebral infarction, was observed eating without the required adaptive equipment on multiple occasions. The resident had difficulty eating without the equipment, and staff only provided the necessary items after being informed of the omission. On one occasion, the plateguard did not fit the plate provided, requiring staff to obtain a different plate. Despite the orders being present on the meal ticket, the adaptive equipment was not consistently provided during meal services.
Deficient Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and sanitation practices within the facility's kitchen and food service areas. Open bags of pasta, bread, and various pantry items were found unsealed and undated, with some items such as a can of pumpkin being dented. Dry cereal and other dry goods were stored in containers without labels or dates, and a box of oil was used to prop open a pantry door. In the refrigerator, several food items including cheese, whipped topping, hamburger patties, pepperoni, pickles, cottage cheese, garlic, eggs, ranch dressing, salad, and hard-cooked eggs were found opened, unlabeled, and undated. The freezer also contained open, unsealed, and undated items such as fries, breakfast items, popsicles, and cookie dough. These findings were confirmed by the Dietary Manager in Training. Additional observations included improper storage and cleanliness of utensils and equipment. Ice scoops were found inside ice chests, and soiled cloths and used gloves were left on or near handwashing and eye wash stations. Staff were observed not wearing required beard coverings while working in the kitchen. The oven and deep fryer were dirty, with crumbs and grease present, and serving utensils were stored with handles facing different directions. The food holding table had food crumbs and liquids dripping onto the floor. These actions and inactions were verified by dietary staff during the survey.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage in accordance with professional food service safety standards. During an observation, the trash dumpsters were found with their lids open, overflowing with bags of trash, and additional garbage such as paper and gloves scattered on the ground below. This situation was confirmed by the Dietary Manager in Training, who also noted that trash collection occurred on Mondays, Wednesdays, and Fridays. The improper disposal and accumulation of refuse had the potential to affect more than a limited number of residents. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents. For one resident with an order prohibiting blood pressure measurements and lab draws from the left upper extremity due to an AV fistula, documentation showed that blood pressure readings were repeatedly recorded as being taken from the restricted limb. However, the resident stated that staff did not actually take blood pressure from that arm, indicating inaccurate documentation. The Director of Nursing acknowledged the documentation error. Another resident had a physician order for NPO status with allowance for ice chips, but the care plan incorrectly stated that the resident received meal trays in addition to tube feedings. This discrepancy between the care plan and physician orders was confirmed by the DON. Additionally, for a third resident, there were days when no documentation was present regarding the amount of nutrition consumed, as verified by the facility's Regional Nurse. These findings were discussed with the facility's Administrator during the exit interview.
Failure to Interview Cognitively Intact Resident During Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with intact cognitive abilities, as indicated by a BIMS score of 15. The incident involved a staff member allegedly yelling at the resident and roughly handling her after she slid out of her recliner. The allegation was reported by the resident's daughter, and the staff member in question was suspended pending investigation. During the facility's investigation, statements were collected from staff members present during the incident. However, the facility did not obtain a statement from the resident herself during the course of the investigation, despite her being cognitively intact and able to provide information. The resident confirmed during an interview with the surveyor that no facility staff had asked her about the incident. The Administrator also confirmed that no statement from the resident was taken, and no further documentation was provided to indicate otherwise.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment with an assessment reference date of 12/31/24 incorrectly indicated the use of a trunk restraint less than daily, despite no physician's orders or care plan documentation supporting current or past restraint use. For another resident, who had a diagnosis of depression since 09/05/23 and had been receiving trazodone for major depression since 08/14/24, the MDS assessment with an assessment reference date of 11/14/24 did not code the diagnosis of depression. These inaccuracies were acknowledged by facility staff during the survey.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans that addressed the specific medical, physical, and psychosocial needs of two residents. For one resident, repeated observations showed the individual lying in bed without a brief, with staff interviews revealing that briefs were not used in bed due to the resident's tendency to rip and chew them. When the resident was up, a one-piece outfit was used to prevent access to the brief. However, the care plan did not document the use of the one-piece outfit or the practice of not using briefs in bed, and this omission was confirmed by the facility's Minimum Data Set Coordinator. For another resident, the care plan included an intervention for a plateguard with meals due to nutritional risk, but this adaptive equipment was not provided during multiple meal observations. The absence of the plateguard was acknowledged by both the Administrator and the Corporate Registered Nurse, and it was found that the plateguard was not listed on the resident's meal ticket. The Registered Dietitian explained that the process for ensuring adaptive equipment is provided relies on nursing staff submitting a communication form to dietary, which had not occurred, resulting in the resident not receiving the required plateguard.
Care Plan Not Updated After Discontinuation of Adaptive Equipment Order
Penalty
Summary
The facility failed to revise the care plan for Resident #14 after the order for adaptive equipment, specifically a Kennedy cup for use during meals, was not renewed following the resident's return from a recent hospital stay. Record review showed that prior to hospitalization, the resident had an active order for a Kennedy cup with all meals, which was discontinued during the hospital stay and not reinstated upon return to the facility. Despite the absence of a current order, the care plan continued to indicate the use of a Kennedy cup. Observations during the survey confirmed that the resident was not provided with a Kennedy cup at meals, and staff interviews verified that the care plan had not been updated to reflect the change in orders.
Failure to Complete Annual Nurse Aide Evaluations
Penalty
Summary
The facility failed to conduct yearly performance evaluations for nurse aides, as required. Specifically, one nurse aide with a hire date of 11/19/18 had their last evaluation completed on 1/25/24, and no current performance review was on file at the time of the survey. This was confirmed by the Regional Director of Operations during staff interview and record review. The deficiency was identified through review of staffing documentation and staff interviews, and it has the potential to affect more than a limited number of residents, given the facility's census of 106.
Expired Insulin Pen Not Discarded After 28 Days
Penalty
Summary
Surveyors observed that a Novolog insulin pen prescribed to a resident was stored in a medication cart beyond the recommended usage period. The insulin pen was labeled with an opening date of 01/10/25 and an expiration date of 02/06/25, but as of 02/18/25, it remained in use. The pharmacy label and the manufacturer's instructions indicated that the insulin should be discarded 28 days after opening if stored at room temperature. The LPN present during the inspection acknowledged that the insulin pen had been open for more than 28 days and should not have been used. Review of the resident's physician orders confirmed an active prescription for Novolog FlexPen insulin as needed for sliding scale coverage. The Medication Administration Record showed that the resident had received doses of the insulin on multiple occasions after the 28-day expiration period had passed. The failure to discard the insulin pen after the recommended timeframe resulted in the medication being available for administration beyond its safe usage period, contrary to accepted professional principles for medication storage and labeling.
Failure to Perform Ordered Laboratory Tests for Two Residents
Penalty
Summary
The facility failed to perform laboratory testing according to physician's orders for two of five residents reviewed for unnecessary medications. For one resident, a physician's order dated 05/03/24 required a basic metabolic panel, complete blood cell count, lipid panel, and liver panel to be completed every six months in April and October. While laboratory results for the basic metabolic panel, complete blood cell count, and lipid panel were available for October 2024, the liver panel was not performed as ordered. The Director of Nursing (DON) confirmed that the liver panel was not completed in accordance with the physician's order. For another resident, a physician's order dated 01/02/25 required a Hemoglobin A1C (HgbA1C) test to be performed every four months, specifically in January, May, and September. The DON was unable to provide laboratory results for the HgbA1C test that was due in January 2025, confirming that the test had not been performed as ordered. No additional information was obtained during the survey process regarding these deficiencies.
Failure to Maintain Infection Control Due to Soiled Clothing Left on Bathroom Floor
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program as evidenced by the presence of dirty clothes lying on the bathroom floor in a resident's room. At approximately 1:50 PM, dirty clothes were observed on the bathroom floor, and a housekeeping aide explained that one of the residents places her clothes on the floor, expecting aides to pick them up during their rounds. This observation was confirmed by an MDS nurse a few minutes later. The incident demonstrates a lapse in infection control practices, as soiled clothing was not promptly removed from the resident's environment.
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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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