Nella's At Autumn Lake Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkins, West Virginia.
- Location
- 499 Ferguson Road, Elkins, West Virginia 26241
- CMS Provider Number
- 515196
- Inspections on file
- 11
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 30 (1 serious)
Citation history
Health deficiencies cited at Nella's At Autumn Lake Healthcare during CMS and state inspections, most recent first.
The facility did not employ a Certified Dietary Manager with proper credentials and lacked a full-time RD, with the RD only present once weekly and otherwise available remotely. The FSM could not provide a staffing policy, and the contracted food service company did not supply the requested documentation. Additionally, not all Nutrition Services Staff had the required food handler certifications, with only a portion of certificates available for review.
Surveyors identified multiple failures in food storage, preparation, and equipment sanitation, including improper labeling and dating of food items, storing disposable utensils and food directly on the floor, and lack of a cleaning schedule for kitchen equipment. These deficiencies had the potential to affect all residents in the facility.
Paper towels were not available at two kitchen handwashing sinks, as observed during a survey walkthrough. The Food Services Manager confirmed that dispensers had not been refilled, resulting in the use of a cleaning towel for hand drying. This lapse in infection control had the potential to impact all residents in the facility.
Two residents reported that shower water was not warm enough for comfortable use, with measured temperatures significantly below the facility's target range. Observations also found poor cleanliness and improper storage of personal hygiene items in the shower rooms, including dirty towels and wash rags left on surfaces and floors, contrary to facility policy.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide sufficient supervision to prevent accidents. The report highlights that the environment did not meet required safety standards, but does not specify further details about those affected.
Several residents did not receive individualized care plans, with generic interventions failing to reflect their specific interests, diagnoses, or needs. Care plans for activities, depression, PTSD, and pain management were incomplete or not updated, and scheduled one-to-one visits were often missed. Staff interviews revealed a lack of interdisciplinary collaboration and insufficient resident involvement in care planning.
The facility did not include residents, responsible parties, or the full interdisciplinary team in care plan meetings, and failed to update care plans when new medications were added. Two residents with intact cognition were unaware of their care plans, and documentation lacked evidence of proper meeting attendance or resident involvement.
Surveyors observed that meals were being served on wet plates because the dishwasher was out of dry assist, resulting in improper drying. The Certified Dietary Manager confirmed the issue and acknowledged the potential for bacterial contamination due to the use of wet plates during meal service.
The facility failed to maintain complete and accurate medical records, including incomplete POST forms lacking required signatures, failure to follow up on ABNs with written documentation after verbal consent, and incorrect admission weight documentation for a resident. Staff interviews revealed a lack of official processes for obtaining and documenting required consents, resulting in incomplete records for several residents.
Surveyors found that a resident's bathroom was not kept clean or comfortable, with dried substances around the toilet, a sticky floor, and a strong urine odor. The Housekeeping Supervisor confirmed the unsanitary conditions.
A resident was transferred to a hospital following a fall, altered mental status, and high blood glucose, but the facility did not document which required transfer documents were sent with the resident. Although a transfer checklist was signed by a nurse and ambulance staff, none of the items were checked to indicate what information was provided to the hospital.
A resident's electronic health record listed diagnoses of anxiety disorder, major depressive disorder, and PTSD, but the most recent MDS assessment only documented PTSD, omitting the other two conditions. The DON confirmed this assessment error during the survey.
Surveyors found that the facility did not update PASARR documentation to reflect new mental health diagnoses for two residents. In both cases, the residents' EHRs listed conditions such as PTSD, anxiety disorder, and major depressive disorder, but these were not accurately recorded on the PASARR forms. The DON and Social Worker confirmed the discrepancies between the EHR, MDS, and PASARR documentation.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided as required.
A resident with PTSD, anxiety, and major depressive disorder was not provided with appropriate social services, as the facility failed to assess for PTSD triggers, include representative input, or make referrals for psychological evaluation. The care plan and social service notes did not address the resident's mental health diagnoses, and staff interviews confirmed these omissions.
Staff failed to follow infection control protocols in two cases: a nurse used bare hands to handle medications that had fallen onto a medication cart before administering them to a resident, and an LPN did not wear a gown while providing enteral feeding care to another resident under enhanced barrier precautions, despite facility policy requiring these measures.
Two residents did not receive necessary speech therapy services before significant changes were made to their diets, including one who experienced a downgrade to puree texture without a speech consult and another with a history of aspiration pneumonia who was not reassessed for swallowing difficulties despite being placed on NPO status. Facility staff confirmed that required consults and evaluations were not completed as per policy.
The facility failed to maintain room temperatures between 71 to 81 degrees Fahrenheit, as observed during a complaint investigation. A registered nurse confirmed the building was hot, and several rooms on the A Hall had non-functional AC units, leading to resident complaints. On the B Hall, room temperatures ranged from 71.2 to 79.4 degrees Fahrenheit, with one room reaching 83 degrees. Residents expressed discomfort, and some were moved to other rooms. The Nursing Home Administrator acknowledged the issue and stated that air conditioners were being procured and parts were pending approval for replacement.
A resident reported a year-long issue with a leaking air conditioner in her room, which was not addressed due to a lack of a work order. The unit's filter was wet, and the fan was non-functional, posing a fall risk.
Failure to Employ Qualified Dietary Manager and Maintain Food Handler Certifications
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) with the appropriate credentials and did not have a full-time Registered Dietitian (RD) on staff. The Food Service Manager (FSM) confirmed during an interview that he was not a CDM, and both the Administrator and Director of Nursing stated that the RD only visited the facility once per week and was otherwise available remotely. The FSM was unable to provide a staffing policy for his position, and attempts to obtain this policy from the contracted food service company, Healthcare Services Group (HCSG), were unsuccessful as no documentation was provided to the surveyor. Additionally, the facility did not ensure that all Nutrition Services Staff possessed the required County/State food handler certifications. Of the ten employees in the department who had been employed for more than 30 days, only three food handler certificates were initially provided, with a total of five eventually located. The remaining certificates could not be produced, and the facility's HR department was unable to account for them. These deficiencies had the potential to affect all residents receiving meals in the facility, which had a census of 96 at the time of the survey.
Food Safety and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety, as well as to maintain kitchen equipment in a safe and clean condition. During a kitchen walkthrough, surveyors observed multiple cases of disposable utensils, plates, and cups stored directly on the floor, which the Food Service Manager (FSM) incorrectly stated was acceptable due to their packaging. An opened bag of breadcrumbs in dry storage was not sealed, labeled, or dated correctly, and two sheet pans of turkey stock in the walk-in refrigerator were missing use-by dates and had not been discarded as required. Additional food items, such as an opened bag of parmesan cheese and a pan of gelatin, were not properly labeled or dated, and some items, like sliced bologna and expired flour tortillas, were found without any labeling or with expired dates and were subsequently discarded by the FSM. The facility also failed to maintain kitchen equipment and cleanliness. The mixer was left uncovered when not in use, and there was ice buildup in the walk-in freezer. The two-door reach-in refrigerator contained debris and liquid spills, and the FSM admitted there was no equipment cleaning schedule in place at the time. Two ovens were soiled with debris, and an oven rack was found sitting directly on the floor. A jar of peanut butter was not labeled with an open or use-by date, and the can opener was observed to be soiled. These deficiencies had the potential to affect all residents in the facility, as indicated by the facility census of 96.
Failure to Maintain Hand Hygiene Supplies in Kitchen
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not ensuring that paper towels were available at two designated handwashing sinks in the kitchen. During a walkthrough, a surveyor observed that the handwashing sink outside the Food Services Manager's office lacked paper towels, and the Food Services Manager confirmed that the dispenser had not been refilled after the last use, instead providing a cleaning towel for hand drying. Additionally, the handwashing sink in the dish room was also found without paper towels, with the Food Services Manager acknowledging that the dispenser should have been refilled but was not. These lapses in maintaining proper hand hygiene supplies had the potential to affect all residents in the facility, which had a census of 96 at the time of the survey. No specific residents or staff were identified as directly affected in the report, and no medical history or conditions were mentioned.
Failure to Maintain Safe, Clean, and Comfortable Shower Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by issues with water temperature and cleanliness in the A Wing shower rooms. Two residents with intact cognitive status (BIMS scores of 14 and 15) reported that the shower water was not sufficiently warm, with one resident opting for bed baths due to discomfort. During an observation, the Maintenance Supervisor measured the shower water temperature after running it for seven minutes, finding it only reached 97.4°F, which was acknowledged as not warm enough for a comfortable shower. Additionally, observations of the A Wing shower rooms revealed poor cleanliness and improper storage of personal hygiene items. Multiple wash rags were stacked on sharps containers, numerous bottles of hygiene products were left on the floor, and towels and wash rags were found on chairs and the floor, some appearing dirty. The Administrator confirmed that these items should not be stored in the shower rooms. A review of facility policy indicated that personal hygiene products should be stored in individual resident rooms or designated storage areas to prevent cross-contamination, which was not being followed.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. Specific actions or inactions by staff or details about the residents involved are not provided in the report.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement individualized care plans for several residents, specifically in the areas of activities, depression, and post-traumatic stress disorder (PTSD). For multiple residents, care plans lacked personalization, with interventions and goals that were generic and did not reflect the residents' specific interests or diagnoses. For example, several residents had care plans that did not specify which activities they enjoyed, despite assessments or staff knowledge indicating clear preferences such as crafts, music, gardening, or social activities. In some cases, activity assessments were missing entirely, and scheduled one-to-one visits were not provided as documented in the care plans. Residents with mental health diagnoses, including depression and PTSD, were not adequately addressed in their care plans. For instance, one resident with documented PTSD and depression had a care plan that only addressed anxiety, omitting the other diagnoses. Another resident's care plan did not mention PTSD at all, despite the diagnosis being present in the medical record. Staff interviews confirmed that these omissions were not due to a lack of awareness but rather a lack of interdisciplinary collaboration and communication during care plan development. The process for creating and updating care plans was found to be insufficiently interdisciplinary. The Activities Director reported not being invited to care plan meetings and not being responsible for writing care plans, while the Social Worker stated that care plans were typically developed by reviewing medical records without input from other departments or the residents themselves. There was also a lack of documentation regarding care plan meeting attendance and resident or representative involvement. Additionally, pain management care plans lacked measurable objectives, timeframes, and individualized details, and there was no evidence of ongoing evaluation or interdisciplinary discussion regarding pain management, even when residents reported pain that interfered with daily function.
Failure to Involve Residents and Interdisciplinary Team in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties, as well as required staff, were included in care plan meetings, and did not revise care plans when new medications were added. For one resident, two psychotropic medications, Tramadol and Lorazepam, were started but not included in the comprehensive care plan. The DON confirmed that these medications were omitted from the care plan, with one medication having been recently initiated. Additionally, the facility's process for care plan development did not involve the full interdisciplinary team as required by policy, and there was no evidence that residents or their representatives were invited to or participated in care plan meetings. Two residents with intact cognition were interviewed and both stated they did not know what a care plan was. Review of documentation revealed no evidence of who attended care plan meetings, and the social worker confirmed that only she and the MDS coordinator were involved in preparing care plans. Letters were mailed to responsible parties, but there was no follow-up to confirm attendance, and in-house residents were not invited or informed about their care plans. These deficiencies affected three residents in a facility with a census of 91.
Food Service Safety Deficiency Due to Use of Wet Plates
Penalty
Summary
During a survey, it was observed that the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the cook was seen preparing and serving meals on wet plates taken directly from the plate holder. When questioned, the Certified Dietary Manager (CDM) confirmed that all the plates being used were wet. Further investigation revealed that the dishwasher was out of dry assist, which resulted in the plates not being properly dried. The CDM acknowledged that serving food on wet plates could draw bacteria. These actions occurred while meals were being prepared and served to residents, with a facility census of 91 at the time.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for multiple residents, particularly in the areas of advance directives, beneficiary notices, and nutrition documentation. For several residents, Physician Orders for Scope of Treatment (POST) forms were incomplete, lacking required signatures from authorized representatives or witnesses, and in some cases, there was no documentation of follow-up to obtain these signatures. The Social Worker acknowledged that there was no official process for securing written consent after verbal acknowledgments, and forms were often not mailed to out-of-state representatives, resulting in incomplete documentation. In one instance, a POST form listed the Department of Health and Human Resources as the official surrogate, but there was no documentation of communication regarding the transition of decision-making authority or confirmation of who currently held legal authority. In addition to deficiencies with POST forms, the facility did not properly complete Advance Beneficiary Notices (ABNs) for two residents. Verbal consent was obtained from representatives, but there was no attempt to follow up with mailed, emailed, or faxed notices as required by facility policy. The Social Worker confirmed that only verbal consent was obtained and cited concerns about postage as a reason for not sending the forms. Facility policy required that if a notice could not be hand-delivered, it should be followed up immediately with a mailed, emailed, faxed, or hand-delivered notice, and documentation should comply with form instructions regarding telephone notices. There was also an error in the documentation of a resident's admission weight. The admission weight recorded in the chart was inconsistent with the weight documented by the hospital and the weight assessed by the Registered Dietician. The DON confirmed that the admission weight in the chart was incorrect and should have been corrected. These failures in documentation and record-keeping led to incomplete and inaccurate medical records for the affected residents.
Failure to Maintain Clean and Homelike Resident Bathroom Environment
Penalty
Summary
A deficiency was identified when surveyors observed that the bathroom in room [ROOM NUMBER]-B was not maintained in a clean and comfortable condition. Specifically, the entire base of the toilet was surrounded by a dried orange, yellow, and brown substance, the floor was sticky, and there was a strong urine odor present in the bathroom. These conditions were confirmed by the Housekeeping Supervisor during an interview, who acknowledged that the bathroom was dirty.
Failure to Document Transfer Information Sent to Hospital
Penalty
Summary
The facility failed to ensure proper documentation that required transfer information was provided to the receiving hospital for a resident who was transferred due to a fall, altered mental status, and elevated blood glucose level. Review of the resident's electronic medical records did not show any documentation regarding what information was sent to the hospital at the time of transfer. The only available document was an Acute Care Transfer Document Checklist, which included instructions for sending specific documents with the resident and required checkboxes to indicate which items were sent. However, none of the items on the checklist were checked to confirm that any information was actually sent with the resident. The checklist was signed by both the nurse and the ambulance staff, but there was no indication of which documents accompanied the resident. The Director of Nursing confirmed that this checklist was the only documentation available regarding the transfer, and no further information was provided during the survey process.
Inaccurate MDS Assessment of Psychiatric Diagnoses
Penalty
Summary
The facility failed to accurately reflect a resident's mental health diagnoses in the Minimum Data Set (MDS) assessment. Record review showed that the resident had documented diagnoses of anxiety disorder, major depressive disorder (recurrent, severe, without psychotic features), and post-traumatic stress disorder (PTSD) in the electronic health record. However, the most recent MDS assessment only marked PTSD under Section I: Active Diagnoses, omitting both anxiety disorder and depression. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged the error.
Failure to Update PASARR with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) documentation when new mental health diagnoses were identified for two of eight residents reviewed during the annual survey. For one resident, the electronic health record (EHR) listed diagnoses of anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD), but the most recent PASARR did not reflect any of these conditions. The PASARR form had options to indicate major depression, PTSD, and anxiety, but none were selected. Additionally, the Medical Diagnostic Screening (MDS) assessment for this resident marked PTSD but did not include anxiety disorder or depression, resulting in inconsistencies between the EHR, MDS, and PASARR documentation. The Director of Nursing (DON) confirmed that the EHR diagnoses were accurate and that the MDS and PASARR were not coordinated with the EHR. For another resident, a diagnosis of PTSD was present in the resident's diagnosis list but was not included on the PASARR. Both the DON and the Social Worker confirmed that the PTSD diagnosis was missing from the PASARR. These findings were based on record reviews and staff interviews, demonstrating a lack of coordination and updating of PASARR documentation when new mental health diagnoses were identified.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and agreed to by the resident, and that proper care was given to those with feeding tubes.
Failure to Address Resident's PTSD and Mental Health Needs
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident in attaining or maintaining their mental and psychosocial health. Upon admission, the resident had diagnoses of Post Traumatic Stress Disorder (PTSD), Anxiety, and Major Depressive Disorder, which were documented in both the medical record and the Pre-admission Screening and Resident Review Assessment. A Social Service Assessment was completed, including a trauma screen, but the resident responded negatively to all trauma-related questions. The assessment did not include input from the resident's representative, nor did it probe for PTSD triggers or address the resident's PTSD diagnosis. The care plan noted a communication problem but did not include goals or interventions for depression or PTSD. There was no referral for psychological evaluation or behavioral services, and the Director of Social Services' notes did not address PTSD. Interviews with the DON and Director of Social Services confirmed that there was no referral for psychological services and that PTSD was not addressed in the care plan or assessments, with the Director of Social Services stating she did not feel further action was necessary due to the negative trauma screen responses.
Failure to Follow Infection Control Practices During Medication Administration and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices as evidenced by two separate incidents involving medication administration and enhanced barrier precautions. In the first incident, a registered nurse was observed administering medications from blister packs to a resident. When two medications fell onto the uncovered medication cart, the nurse used her bare fingers to place the medications into a cup for administration, contrary to facility policy which prohibits touching medications with bare hands and requires discarding medications that fall onto surfaces. The Director of Nursing confirmed that these actions were not in accordance with facility policy. In the second incident, a licensed practical nurse was observed providing care to a resident with a gastrostomy tube and an order for enhanced barrier precautions due to wounds and the feeding tube. The nurse wore gloves but failed to wear a gown while flushing the gastrostomy tube and connecting enteral feeding, despite facility policy and posted signage requiring both gloves and a gown for such high-contact care activities. The Director of Nursing confirmed that a gown should have been worn during this procedure.
Failure to Provide Required Speech Therapy Services for Residents with Swallowing and Dietary Needs
Penalty
Summary
The facility failed to provide specialized rehabilitative services, specifically speech therapy, for two residents who required such interventions. For one resident, the diet was downgraded from regular texture to puree texture due to ongoing weight loss, but there was no speech therapy consult prior to this significant change. The registered dietician confirmed that such a downgrade should not occur without a speech consult, and the DON acknowledged that staff had not been following the necessary steps for diet changes involving texture modifications. Another resident, who had a history of recurrent aspiration pneumonia and multiple hospitalizations for related complications, was placed on an NPO (nothing by mouth) diet. Despite the resident's reports of not receiving speech therapy for swallowing difficulties and expressing a desire to eat, there was no recent SLP evaluation or swallowing study. The last SLP evaluation was over a year prior, and the resident had not received swallowing therapy or exercises, nor any recent diagnostic tests to reassess swallowing ability. The facility's process for speech therapy referrals relied on telehealth evaluations and outpatient services, but there was no evidence of timely or adequate reassessment for this resident despite significant changes in condition and repeated hospitalizations. Interviews with facility staff revealed gaps in the interdisciplinary team (IDT) process, with daily meetings occurring but no formal IDT meetings to discuss significant changes or therapy needs. The facility's screening policy required therapy services for new admissions and readmissions, but in these cases, the necessary speech therapy consults and evaluations were not completed as required, leading to a failure to provide appropriate specialized rehabilitative services.
Failure to Maintain Adequate Room Temperatures
Penalty
Summary
The facility failed to maintain resident room temperatures within the required range of 71 to 81 degrees Fahrenheit, as observed during an unannounced complaint investigation. Upon entering the building, a registered nurse confirmed that the building was hot, particularly on the B side, and mentioned that parts had been ordered to address the issue. During a tour of the A Hall, several rooms were found to have inadequate air conditioning, with some units not functioning at all, leading to resident complaints about the heat. Specific issues included non-functional AC units, little air circulation, and leaking units, which had been reported to the Maintenance Director and Nursing Home Administrator. The investigation revealed that room temperatures on the B Hall ranged from 71.2 to 79.4 degrees Fahrenheit, with one room reaching 83 degrees Fahrenheit. Residents expressed discomfort due to the heat, and some were moved to other rooms. The Nursing Home Administrator acknowledged the problem and stated that room air conditioners were being procured and that an AC company had inspected the units, with parts pending approval for replacement. Despite these acknowledgments, the deficiency in maintaining a safe and comfortable environment persisted at the time of the investigation.
Failure to Maintain Functioning Air Conditioner
Penalty
Summary
The facility failed to maintain a functioning room air conditioner in a resident's room on A Hall, leading to a deficiency. A resident reported that the air conditioning unit had been leaking water onto the floor since her admission approximately a year ago. She expressed concern about the potential risk of falling due to the water on the floor. Upon observation, the air conditioning unit's filter was found partially pulled out and wet, and the unit's fan was not operational. The Nursing Home Administrator (NHA) was informed of the leak, and the Maintenance Director confirmed that there was no work order for the issue. The Maintenance Director identified that the drain tube was plugged, which was subsequently addressed.
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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