New Martinsville Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in New Martinsville, West Virginia.
- Location
- 225 Russell Avenue, New Martinsville, West Virginia 26155
- CMS Provider Number
- 515074
- Inspections on file
- 22
- Latest survey
- October 16, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at New Martinsville Health & Rehab during CMS and state inspections, most recent first.
A resident with a physician's order for residual checks and tube placement verification prior to each tube feeding did not receive care in accordance with these orders. An LPN administered a tube feeding without performing the required residual check, stating she was unaware of the order and typically waited longer after meals. The administrator confirmed the orders should have been followed.
Surveyors observed that all facility dumpsters were overflowing, with lids unable to close and soiled gloves, bags, and miscellaneous trash scattered around the dumpsters. The Administrator confirmed these conditions, which were not in compliance with the facility's policy requiring dumpsters to be kept closed and free of surrounding litter.
Surveyors found that expired beverages were stored in the kitchen refrigerator, a dented can was present in dry storage, and individually wrapped crackers were kept undated and in unmarked containers in nourishment rooms. Both the Kitchen Manager and Regional Kitchen Manager acknowledged these lapses, which were not in accordance with the facility's food storage and labeling policies.
Multiple residents experienced unsafe and unclean living conditions, including a black substance on bathroom tiles, missing drywall, a large hole in a ceiling, and a broken toilet with the lid removed. These deficiencies were confirmed by staff and maintenance leadership.
A resident's Pre-admission Screening (PAS) did not include a diagnosis of generalized anxiety disorder (GAD), despite this diagnosis being added to the medical record during their stay. This omission was confirmed through record review and staff interview.
A resident's medical record contained a physician's order for Lamictal 200mg for seizures, but the resident did not have a seizure diagnosis. An LPN confirmed the correct diagnosis should have been mood disorder, resulting in an inaccurate and incomplete medical record.
The facility did not notify a resident's legal representative of the resident's death, resulting in the representative learning of the death from the funeral home. Additionally, another resident's MPOA was not informed when a new medication was ordered for anxiety, and there was no documentation of a change in condition or notification. Both deficiencies were identified through record review and interviews, and the facility's policies requiring such notifications were not followed.
The facility failed to prevent abuse and neglect, leaving a resident with mobility issues unattended outside and not addressing verbal threats from two residents. One resident was left in the courtyard without assistance, while another resident with a history of mental health issues made aggressive threats. The facility did not properly notify physicians or representatives, and the threatening resident had not seen a psychiatrist as ordered.
The facility failed to maintain the dishwasher at the required temperatures, operating below the manufacturer's specifications since April 2024. The Maintenance Director was aware of the issue but indicated that the leasing company needed to fix it. Additionally, a resident's personal refrigerator was not monitored for temperature as required, with no temperature sheet available and staff unaware of the procedure for daily checks.
A resident dependent on staff for wheelchair mobility was left unattended in the courtyard multiple times after smoke breaks, unable to reenter the facility independently. The resident reported being left in the hot sun for extended periods, with no means to notify staff for assistance. Observations showed a lack of call lights or push buttons in the courtyard, and the Administrator confirmed awareness of the incidents.
A resident with paranoid schizophrenia, depression, and dementia exhibited violent behaviors and made threats without receiving necessary psychiatric care. Despite a physician's order for a psychiatrist consult, the resident did not receive the evaluation or follow-up care. Incidents of aggression were not properly reported to the physician or state agencies, creating an immediate jeopardy situation.
The facility failed to maintain an effective infection prevention and control program, as PPE was not readily available for staff in areas with residents on Enhanced Barrier Precautions. During a facility tour, it was noted that three out of four hallways lacked accessible PPE, despite multiple residents being on EBP. Staff interviews revealed they were unaware of the PPE's location or confirmed its absence, indicating a lapse in infection control measures.
A resident was observed in the dining area with an improperly tied gown, exposing parts of their body, while staff failed to assist. Additionally, dining staff served meals on trays, creating an institutional atmosphere. Interviews revealed staff were unaware of the need for a homelike dining experience.
The facility failed to honor residents' food preferences due to a policy requiring alternate meal orders to be placed two hours in advance. This policy prevented residents from exercising their right to choose meals during mealtimes, as they were often occupied with other activities. The Dietary Manager confirmed the policy, noting that residents could order alternates during meals but would have to wait until after meal service.
The facility failed to recognize verbal complaints about call light response times as grievances, despite the Resident Council raising the issue for six months. Although random audits showed no issues, the persistent complaints were not formally documented or addressed, contrary to the facility's grievance policy.
The facility failed to report incidents of abuse, neglect, and possible crime involving three residents to the required state agencies. One resident had illegal substances found in her room, another was left outside unattended, and a third experienced verbal abuse from another resident. The facility did not utilize current reporting guidelines.
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASARR) for three residents, resulting in unrecorded mental health diagnoses such as bipolar disorder, schizophrenia, and seizure disorder. The omissions were confirmed by the facility's social worker, who acknowledged that the necessary updates to the PASARR had not been completed.
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, leading to errors in pronoun usage and discrepancies in code status documentation. Additionally, a resident with multiple diagnoses did not receive a psychiatric consultation as ordered, indicating a lack of care plan implementation.
A facility failed to provide scheduled twice-weekly showers to a resident with an ADL self-care performance deficit. The resident, who requires assistance for bathing, reported not receiving the scheduled showers, and documentation confirmed showers were only provided three times in the past month. The Regional Director of Clinical Operations confirmed the deficiency.
The facility failed to provide adequate care and documentation for several residents. A resident with a history of falls did not receive proper medication management and monitoring as recommended. Another resident's diabetic care was compromised due to missing blood sugar and lab documentation. The facility also neglected to offer RSV vaccinations or provide related educational information. Additionally, a resident's weight monitoring was incomplete, with missing records for specific weeks.
The facility failed to administer pain medication according to physician orders for two residents. One resident received Hydrocodone-Acetaminophen for low pain levels, contrary to orders, and did not receive prescribed Acetaminophen. Another resident was given Oxycodone for mild pain and Tylenol for severe pain, against prescribed guidelines. These discrepancies were confirmed by the Director during interviews.
The facility failed to properly store garbage and refuse, with an open dumpster lid and a trashcan full of trash without a lid, leading to pollution with garbage and medical supplies. The Maintenance Assistant confirmed the lids should be closed and needed help lifting the trash can over the dumpster.
The facility failed to maintain accurate medical records for residents, with issues found in the Physician Orders for Scope of Treatment (POST) forms. A resident's POST form was not dated, making it legally invalid, while another resident's form lacked a required signature, only having verbal consent. Additionally, discrepancies were found between a resident's POST form and their care plan and physician's orders.
The facility did not develop policies to prioritize performance improvement activities, leading to a failure to address verbal abuse allegations systematically. Five out of eight complaints involved staff verbally abusing residents, but the QAA Committee did not identify this pattern as an area for improvement. Incidents were treated individually without a systems-level approach.
The facility failed to maintain the ice machine in the main dining room according to manufacturer's recommendations. The water drainpipe was improperly connected directly into the sewer pipe without the required two-inch air gap, and both pipes were covered with a black substance. This was confirmed by the Director of Dietary.
The facility's pest control program was found to be ineffective, as ants were observed in the kitchen's dishwashing room. The Maintenance Director acknowledged the issue, noting that the facility lacks an exterminator spray for roaches or ants and relies on staff to spray when insects are seen. The exterminator only places bait in traps outside, which does not address the indoor ant problem. This deficiency could potentially impact all 88 residents.
A facility failed to provide timely Notification of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for a resident whose Medicare Part A services ended. The notices were issued four days late, contrary to the requirement to deliver them at least two days before the end of coverage. The Business Office Manager confirmed the delay.
A resident unable to propel her wheelchair independently was left unattended outside multiple times after smoke breaks, with no means to notify staff. The facility's policy required reporting such neglect, but the Administrator did not report the incidents, as they were not considered neglectful. Observations showed a lack of call lights or push buttons in the courtyard, and the resident's care plan indicated she required assistance for mobility.
A facility failed to respond adequately to neglect and verbal abuse allegations involving two residents. One resident was left outside alone multiple times after smoke breaks, unable to reenter the facility independently. Another resident reported verbal abuse and threats from a fellow resident, leading to distress and a desire to leave the facility. The facility did not investigate or report these incidents properly, nor did it implement effective preventive measures.
The facility failed to provide written Notices of Transfer or Discharge to residents or their representatives and did not notify the LTC Ombudsman for two residents transferred to the hospital. The Medical Records Director and Social Worker confirmed the absence of required documentation for these transfers.
The facility failed to provide necessary notifications and documentation for residents transferred to hospitals. A resident was discharged without a Notice of Transfer or Discharge being provided to their representative, and the Ombudsman was not notified. Another resident's hospitalization lacked evidence of a Bed Hold notice, as confirmed by the Medical Records Director. Additionally, a third resident's record lacked documentation of a Bed Hold Policy notice during hospitalization, confirmed by the Social Worker.
A facility failed to update the PASARR for a resident after they were diagnosed with major depressive disorder and bipolar disorder post-admission. The PASARR submitted did not include these new diagnoses, which was confirmed by the social worker during an interview.
A facility failed to obtain laboratory services as ordered for a resident with Diabetes Mellitus II. The resident had orders for Novolog Injection Solution and regular CBC and HgbA1c tests. Upon review, the most recent test results were missing, and the ADON confirmed the tests had not been conducted as ordered.
A resident reported ceiling damage in her room, with brown spots and a hole from which drywall was extruding. The Maintenance Supervisor confirmed the damage was due to water issues, highlighting a failure to maintain a safe and comfortable environment.
The facility failed to update and post daily nurse staffing information in a prominent place accessible to residents and visitors. An observation on a specific day revealed outdated staffing information, and the Medical Records Director confirmed the lack of updates for several days.
Failure to Follow Physician Orders for Tube Feeding
Penalty
Summary
A deficiency occurred when a physician's order for a resident receiving tube feedings was not followed. The medical record indicated that the resident required residual checks prior to each tube feeding, with specific instructions to hold the feed and recheck if residuals exceeded 200ml, and to notify the physician if residuals were greater than 500ml. Additionally, the order required verification of tube placement before medication administration or feeding. During an observation, an LPN administered a tube feeding without checking the residual as ordered. When interviewed, the LPN stated she was unaware of the order to check residuals prior to feeding and explained her practice of waiting longer after breakfast to avoid the resident becoming too full. The administrator confirmed that the physician's orders should have been followed.
Improper Containment and Disposal of Kitchen Waste
Penalty
Summary
The facility failed to properly contain and dispose of kitchen waste in accordance with its own policy and state laws. On the morning of 08/20/25, surveyors observed that all facility dumpsters were overflowing, with lids unable to close and soiled gloves, bags, and miscellaneous trash scattered around all sides of the dumpsters. The Administrator confirmed these observations when notified. Review of the facility's policy titled 'Food-Related Garbage and Refuse Disposal' revealed that outside dumpsters are required to be kept closed and free of surrounding litter, which was not adhered to during the survey.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
Surveyors observed multiple failures in food storage practices within the facility's kitchen and nourishment rooms. During an initial kitchen walkthrough, expired beverages including cranberry juice, fruit punch, grape drinks, sugar-free drinks, and unsweet tea were found in the walk-in refrigerator, all past their labeled use-by dates. The Kitchen Manager acknowledged the presence of these expired items. Additionally, a dented can of Sysco Classic Spaghetti Sauce was found in dry food storage, which was also acknowledged by the Kitchen Manager. The facility's policy requires all foods stored in refrigerators or freezers to be covered, labeled, and dated, and dry foods stored in bins to be removed from original packaging, labeled, and dated with a use-by date. Further observations in the nourishment rooms revealed that individually wrapped crackers were stored undated and in unmarked containers or drawers alongside other foods and snacks. The Regional Kitchen Manager confirmed that while some snack boxes were labeled and dated, they were unaware of the lack of labeling for the graham crackers and their continual placement in unmarked drawers. The facility's documented procedures require all foods to be received and stored in compliance with safe food handling practices, including proper labeling and dating, which was not consistently followed in these instances.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple deficiencies observed and reported. One resident reported a black area on the tile and base of the wall behind the toilet, which was confirmed by observation and acknowledged by a nurse aide. Another resident stated that pieces of drywall had been removed from the bathroom wall around the toilet pipes for about a month, and that he did not have access to his toilet for two weeks, requiring him to use the nurse’s station toilet. A large hole in the ceiling exposing unfinished wood was observed in another resident’s room. Additionally, a toilet lid was found sitting on the floor beside the toilet in another resident’s room, and a nurse aide reported the toilet was broken. The Regional Director of Facilities for Maintenance acknowledged all these issues during interviews and observations.
Incomplete Pre-admission Screening for Psychiatric Diagnosis
Penalty
Summary
The facility failed to provide a complete Pre-admission Screening (PAS) for a resident, as required. Specifically, the PAS dated 07/01/24 did not include the diagnosis of generalized anxiety disorder (GAD), even though this diagnosis had been added to the resident's medical record during their stay on 06/16/23. This omission was identified during a record review and confirmed by a staff interview with the Social Service Worker, who acknowledged that the diagnosis was missing from the PAS. The deficiency was noted for one of three residents reviewed during the survey, with a facility census of 93 at the time of the survey.
Incomplete and Inaccurate Medical Record for Medication Order
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident. During a record review, a physician's order was found for Lamictal 200mg to be administered at bedtime for seizures; however, the resident's diagnoses did not include seizures. Further review and staff interview confirmed that the resident did not have a seizure diagnosis and that the correct diagnosis should have been mood disorder. This discrepancy resulted in the resident's medical record not reflecting accurate and complete information in accordance with accepted professional standards.
Failure to Notify Resident Representatives of Death and Medication Changes
Penalty
Summary
The facility failed to notify a resident's legal representative of the resident's death and failed to notify another resident's representative of a new medication order. In the first case, the legal representative of a resident who passed away was not successfully contacted by the facility, despite multiple documented attempts to reach her by phone. The legal representative reported not receiving any calls or voicemails from the facility and only learned of the resident's death when contacted by the funeral home. Documentation in the medical record showed that the nurse attempted to call both listed phone numbers but was unable to reach the representative. The facility's policy required that the family or representative be informed of a resident's death, but there was no evidence that successful notification occurred. In addition, the facility did not notify the medical power of attorney (MPOA) for another resident when a new medication, Vistaril, was ordered for anxiety following a psychiatric evaluation. The record review confirmed that the MPOA was not informed of the medication change, and there was no documentation of a change in condition or notification. During an interview, the MPOA stated they were unaware of any anxiety issues and had not been notified about the new medication order. Both deficiencies were identified through record review, policy review, and interviews with resident representatives and staff. The facility's own policies outlined the requirement to notify resident representatives of significant changes, including death and new medication orders, but these procedures were not followed in the cases reviewed.
Failure to Prevent Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to prevent abuse and neglect of residents, as evidenced by several incidents involving different residents. One resident, who was dependent on staff for wheelchair mobility, was left outside unattended in the facility courtyard following a smoking break. This resident reported being left outside alone on multiple occasions, unable to reenter the facility independently due to tremors and a history of falling from the wheelchair. The resident was left in the hot sun for an extended period without a means to notify staff, which was confirmed by a grievance form and medical records. Additionally, the facility failed to protect residents from verbal threats made by two other residents. One resident, with a history of paranoid schizophrenia, depression, and unspecified dementia, made several aggressive and threatening statements towards other residents and staff. These incidents were documented in the resident's progress notes, but there was a lack of proper notification to the physician and resident representatives, and the resident had not seen a psychiatrist as ordered. Another resident was reported to have verbally abused and threatened another resident, causing significant distress and anxiety. The facility's failure to address these issues placed residents in immediate jeopardy, as determined by the state agency. The incidents involving verbal threats and neglectful supervision of residents with mobility issues highlighted significant deficiencies in the facility's ability to protect residents from abuse and neglect.
Removal Plan
- Certified nursing aid suspended pending investigation. Administrator suspended pending investigation. Incident involving resident #29's allegation of being left outside in the sun for extended period reported to APS, Ombudsman and OHFLAC. Head to toe assessment performed on resident #29 to ensure no adverse effects. Incidents involving verbal threats by resident #61 reported to APS, OHFLAC and ombudsman. Resident #61 placed on one-on-one observation until see and cleared by psychiatric services. Incident involving Resident #11 allegation of verbal abuse reported to APS, OHFLAC and Ombudsman. Psychosocial follow up provided for resident #86. Resident #11 continues to follow with psych services as ordered.
- All residents residing in the facility have the potential to be affected. All capable residents will be interviewed to ensure no other allegations of abuse and all residents not able to be interviewed will have skin checks to ensure no sign or symptoms of abuse with corrective action immediately upon discovery. Whole house audit completed on residents having behaviors and ordered psychological services to ensure services provided with corrective action upon discovery.
- All staff will be re-educated on identifying, reporting, and preventing abuse or upon return to work. All staff will be re-educated on smoking policy to include staff supervising and assisting residents out and in during designated smoking times or upon return to work. Daily rounding audits completed by department heads regarding abuse and neglect concerns or transportation to and from smoking concerns with correct action immediately upon discovery.
- Nursing Home Administrator (NHA)/designee will bring results of audits to Quality Improvement Committee (QIC) for review monthly for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by QIC.
Dishwasher Temperature and Refrigerator Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions regarding the dishwasher temperature, which is crucial for maintaining a safe and sanitary food service environment. Observations and facility records revealed that the dishwasher was operating at temperatures significantly below the required levels since April 2024. Specifically, the wash and rinse cycles were both running at 110 degrees, whereas the operating manual specified a minimum of 120 degrees, with a recommended temperature of 140 degrees. An observation on June 3, 2024, confirmed that the dishwasher was only reaching 100 degrees. The Maintenance Director acknowledged awareness of the issue since April 2024 but indicated that the facility did not own the dishwasher, and the leasing company would need to address the malfunction. Additionally, the facility failed to monitor the temperature of a personal refrigerator in a resident's room, as there was no evidence of temperature checks being conducted per protocol. A CNA confirmed the absence of a temperature sheet for the refrigerator and expressed uncertainty about the procedure for ensuring daily temperature checks. A new order was placed in the electronic medical record on June 3, 2024, directing daily temperature checks to begin the following day. This oversight in monitoring refrigerator temperatures could potentially impact the safety and quality of food storage for the resident.
Removal Plan
- Dishwasher was taken out of use. Regional Maintenance Director contacted EcoLab for dishwasher service.
- Whole house audit completed by Director of Nursing/designee to ensure all plates, utensils and water pitchers were taken out of resident's rooms and not in use.
- All staff will be educated to use paper products for any food or fluid services until the dishwasher is repaired and working at recommended temperatures. Meal service and fluid pass will be observed three times a day to ensure disposable paper products are being used for residents until dishwasher is serviced by Ecolab. Once dishwasher is serviced, staff will be re-educated on manual instructions and machine operations, who to report to when systems are out of range and maintenance to escalate when needing service. Pots/pans and cooking utensils will continue to be cleaned and sanitized via three sink/compartment method.
- Nursing Home Administrator (NHA)/designee will bring results of audits to Quality Improvement Committee (QIC) for review monthly for any additional follow-up and/or in servicing until the issue is resolved and randomly thereafter as determined by QIC.
Resident Left Unattended in Courtyard
Penalty
Summary
The facility failed to ensure a safe environment for Resident #29, who was dependent on staff for wheelchair mobility. The resident was left unattended in the facility courtyard on multiple occasions following smoke breaks. Resident #29, who was unable to propel her wheelchair independently due to tremors, reported being left outside alone in the hot sun for extended periods, including one instance where she was left for two hours. The resident had no means to notify staff that she needed assistance to reenter the facility. The facility's records showed a grievance filed on 05/13/24, where a nursing assistant left Resident #29 outside, stating that if she couldn't bring herself inside, she shouldn't be able to smoke. Another resident alerted staff, and the resident was assisted back inside after being left alone for an hour. Additionally, a nursing note from 05/22/24 indicated that the resident was left outside again, leading to her being very upset and tearful. The resident's medical records also noted a history of falling from her wheelchair, further highlighting her vulnerability. Observations of the facility courtyard revealed a lack of call lights or push buttons for residents in wheelchairs to use, preventing them from seeking assistance. The Administrator acknowledged awareness of two instances where Resident #29 requested to remain outside after smoke breaks but confirmed that the resident was unable to reenter the facility independently. This deficiency placed Resident #29 and other residents with mobility issues at risk of harm due to environmental hazards.
Failure to Provide Psychiatric Care for Resident with Mental Disorders
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with paranoid schizophrenia, depression, and unspecified dementia with moderate agitation. The resident, who was admitted from an acute behavioral and mental health hospital, exhibited violent behaviors and made threatening statements on multiple occasions. Despite having a physician's order for a psychiatrist consult, the resident did not receive the necessary psychiatric evaluation or follow-up care. The resident's aggressive behavior was documented in progress notes, including incidents where the resident threatened other residents and staff. On one occasion, the resident yelled at another resident and threatened violence if touched again. In another instance, the resident expressed a desire to harm others if he had a weapon. Additionally, the resident made repeated threats to a CNA during care. These incidents were not properly reported to the physician or the resident's representative, and there was no documentation of any follow-up by the physician. The facility administrator acknowledged the lack of documentation and reporting to the appropriate state agencies. The incidents were not reported to Adult Protective Services or the Office of Licensure and Certification. Furthermore, the resident had not seen the psychiatrist as ordered, indicating a failure to provide essential mental health services and treatment, creating an immediate jeopardy situation for the resident and others in the facility.
Inadequate PPE Availability for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of readily available Personal Protective Equipment (PPE) for staff in areas where residents were under Enhanced Barrier Precautions (EBP). During a tour of the facility, it was observed that three out of four resident hallways had multiple residents on EBP, yet no PPE was accessible to staff. This deficiency was identified during a random opportunity for discovery and had the potential to affect more than a limited number of residents, with the facility census being 86. Specific observations included the absence of PPE on A Hall, C Hall, and D Hall. Interviews with staff members, including two Licensed Practical Nurses (LPNs) and a Certified Nursing Assistant (CNA), revealed that they were unaware of the location of the PPE or confirmed that it was not present where it was typically stored, such as on linen carts. The staff's inability to locate PPE indicates a breakdown in the facility's infection control measures, which are crucial for preventing the transmission of communicable diseases and infections among residents.
Failure to Provide Dignified Care and Dining Experience
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence and self-determination, as evidenced by the observation of Resident #60 in the dining area. Resident #60 was seen wearing a facility gown that was not properly tied, exposing their upper chest, shoulders, and the right side of their back. Despite several staff members passing by, none offered assistance to adjust or tie the gown to cover the exposed areas. This lack of action was acknowledged by Employee #96 during an interview, who confirmed that the gown should have been tied to prevent exposure. Additionally, the facility did not provide a dignified dining experience for the residents. During an observation, it was noted that dining room staff failed to remove food from trays and place it directly in front of the residents, instead leaving the trays in front of them. This practice contributed to an institutional atmosphere rather than a homelike setting. Interviews with Activity Assistant #102 and Dietary Manager #90 revealed a lack of awareness regarding the importance of serving food in a homelike manner. Both staff members cited safety concerns as the reason for keeping food on trays, indicating a misunderstanding of the facility's dining service expectations.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor residents' food preferences and choices, as evidenced by interviews and document reviews. Residents were unable to order alternate food items during mealtimes due to a facility policy requiring orders to be placed two hours in advance. This policy hindered residents' ability to exercise their right to choose their meals, as they were often occupied with other activities and unable to review the menu in time. Resident #17 expressed difficulty in ordering alternatives due to her morning schedule, which included physical therapy and other activities, leaving her with little time to review the lunch menu and place an order. Similarly, Resident #14 reported being unable to order alternate items if he did not like the food served at mealtimes. He mentioned that the policy made it impossible to get an alternate item during meals unless he waited until the kitchen staff had finished serving all residents. Both residents indicated that the previous system of providing a daily menu allowed them to make choices more effectively. The Dietary Manager confirmed the policy and acknowledged that residents could order alternates during mealtimes but would have to wait due to the cooks being busy with meal service.
Failure to Address Resident Grievances on Call Light Response Times
Penalty
Summary
The facility failed to identify verbal complaints and concerns as grievances, specifically regarding the timeliness of call light responses. Over a six-month period, the Resident Council consistently voiced concerns about call lights not being answered promptly during their monthly meetings. Despite these repeated concerns, the facility did not file any grievances related to this issue. The administrator acknowledged awareness of the complaints and stated that random call light audits had been conducted since January, with no issues documented. However, the persistent nature of the complaints suggests that the audits may not have effectively addressed the residents' concerns. The facility's grievance policy requires that all grievances, complaints, or recommendations from resident or family groups concerning resident care be considered and responded to in writing. The social worker confirmed that the Resident Council had raised the issue of call light response times for at least six months, yet no formal grievance was filed. This oversight indicates a failure to adhere to the facility's grievance policy, as the concerns were not formally documented or addressed in writing, despite ongoing resident dissatisfaction.
Failure to Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report allegations of verbal abuse, neglect, and possible crime to all required state agencies, affecting three residents. For Resident #79, illegal substances were found in her room, but the facility did not report this incident to the Office of Health Facility Licensure and Certification (OHFLAC) or other required state agencies. The Regional Director of Operations (RDO) and the Administrator confirmed the lack of reporting, and the police did not file a report or charges. Resident #29 reported being left outside alone in the courtyard multiple times after smoke breaks, unable to reenter the facility due to her inability to propel her wheelchair independently. The facility's grievance forms and medical records corroborated her claims, showing instances where she was left unattended in the heat. Despite being aware of these incidents, the Administrator did not consider them neglectful and did not report them to the required state agencies. Resident #86 experienced verbal abuse and threats from another resident, Resident #11. The facility's response was limited to offering a room change, which Resident #86 refused. The facility reported the abuse to the Ombudsman but failed to submit a Facility Incident Report (FRI) to OHFLAC. The Administrator believed they were following the reporting requirements, but the facility was not utilizing the current guidelines for reporting.
Failure to Accurately Reflect Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) process accurately reflected the mental health diagnoses of three residents. Resident #79 was admitted with a bipolar disorder diagnosis, but the Pre-Admission Screen (PAS) completed by the referring hospital did not include this diagnosis. The facility's social worker confirmed that the omission was overlooked, and as a result, the resident's condition was not evaluated through the Level II PASARR process. Resident #58 had multiple mental health diagnoses, including Paranoid Personality, Schizophrenia Disorder, Bipolar Disorder, Anxiety Disorder, Depression, and Schizoaffective Disorder Bipolar Type. However, the PASARR dated 02/28/22 incorrectly marked the current diagnosis as 'None.' The social worker acknowledged that the mental health diagnoses were not up to date and was in the process of updating the PASARR. Resident #61 had diagnoses of Paranoid Schizophrenia, Psychotic Disorder, and Seizure Disorder prior to admission, but these were not identified on the PASARR submitted on 02/08/24. The facility's social worker confirmed the presence of these diagnoses upon admission and acknowledged that a new PASARR had not been completed to include these conditions.
Deficiencies in Care Plan Implementation and Personalization
Penalty
Summary
The facility failed to ensure that each resident had a person-centered comprehensive care plan developed and implemented to meet their preferences and goals, addressing their medical, physical, mental, and psychosocial needs. This deficiency was identified for five residents during the Long-Term Care Survey Process. For three male residents, the care plans incorrectly referred to them using female pronouns, indicating a lack of attention to personal details and preferences. The Activities Director acknowledged these errors, which were confirmed by the Social Worker. Additionally, there was a discrepancy in the care plan for another resident regarding their code status, which did not align with the Medical Power of Attorney's wishes as documented in the Physician's Order for Scope of Treatment. Furthermore, the facility failed to implement a care plan intervention for a resident with multiple diagnoses, including Paranoid Schizophrenia and Dementia, who had an order for a psychiatric consultation. The facility Administrator was unable to confirm whether the resident had been seen by psychiatric services as ordered, and later acknowledged that the care plan had not been implemented. These findings highlight a pattern of inadequate care planning and implementation, affecting the residents' ability to receive care that aligns with their documented needs and preferences.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to a dependent resident, specifically in the area of bathing. Resident #29, who has an ADL self-care performance deficit and requires assistance for bathing, reported not receiving the scheduled twice-weekly showers. The resident was scheduled to receive showers on Tuesdays and Sundays, but documentation showed showers were only provided on three occasions over the past 30 days, with no refusals recorded. This deficiency was confirmed by the Regional Director of Clinical Operations, who acknowledged that the resident had not received the scheduled showers.
Deficiencies in Medication Management, Diabetic Care, Immunization, and Monitoring
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For Resident #39, the facility did not follow recommendations from a pharmacist consultation report regarding medication management to prevent falls. Despite a recommendation to change the dosing time of Nuplazid to bedtime and monitor orthostatic blood pressures, the medication was administered at 09:00 AM without documentation of the required blood pressure monitoring. The facility's ADON and Medical Director were unable to provide documentation or rationale for the medication timing change or confirm the completion of the orthostatic blood pressure checks. Resident #41's care was compromised due to missing documentation related to blood sugar monitoring and lab tests. The resident had specific orders for insulin administration based on blood sugar levels and periodic lab tests, including CBC and HgbA1c. However, the facility's records showed multiple instances of missing documentation for these orders. The ADON was unable to locate the required lab results or confirm if the tests had been conducted, indicating a lapse in the resident's diabetic care management. Additionally, the facility did not offer RSV vaccinations to residents during the Fall immunization period of 2023, nor did they provide educational information about the vaccine's risks and benefits. This oversight was confirmed by the Infection Preventionist, who acknowledged the lack of information and guidance provided to residents. Furthermore, Resident #191's records showed missing weekly weight measurements as ordered by the physician, with no weights recorded for specific weeks. The facility was unable to produce the missing weight records, highlighting a failure in monitoring and documentation of the resident's health status.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, as evidenced by the administration of pain medication not in accordance with physician orders. For Resident #69, the medical records indicated that Hydrocodone-Acetaminophen was administered for pain levels 1-3, despite the physician's order specifying its use for pain levels 4-10. Additionally, Acetaminophen, which was prescribed for pain levels 1-3, was not administered at all. This discrepancy in medication administration was confirmed by the Director during an interview. Similarly, Resident #80's pain management was not conducted per physician orders. The records showed that Oxycodone was given for a pain level of 3, although it was prescribed for moderate pain levels 4-6. Furthermore, Tylenol was administered for a pain level of 8, which was not in line with the prescribed use for lower pain levels. The Director also confirmed these inconsistencies during an interview. These findings indicate a failure in adhering to professional standards of practice in pain management, as the facility did not ensure that residents received medications according to their prescribed pain levels. This oversight was identified during a revisit survey, highlighting deficiencies in the facility's pain management protocols for the residents involved.
Improper Garbage Disposal
Penalty
Summary
The facility failed to properly store garbage and refuse, as observed in the dumpster area. On June 10, 2024, the dumpster lid was found open, and a trashcan full of trash was without a lid, leading to pollution of the area with garbage and medical supplies. This situation had the potential to affect all 88 residents residing in the facility. During an interview on the same day, the Maintenance Assistant confirmed that the dumpster lids should be closed and that garbage should not be on the ground. He also mentioned needing assistance to lift the trash can over the top of the dumpster and believed the trash had been there only since that day.
Inaccurate and Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents, specifically regarding the Physician Orders for Scope of Treatment (POST) forms. For Resident #79, the POST form was found to be incomplete as it was not dated by the resident, rendering it legally invalid according to the guidelines provided by the Virginia Center for End of Life. This issue was acknowledged by the facility's Social Worker during an interview, confirming that the form was not completed according to the required standards. For Resident #3, the POST form lacked a mandatory written signature from the Medical Power of Attorney (MPOA), as only verbal consent was obtained via telephone, which does not meet the 2017 Virginia POST form regulations. The Social Worker confirmed this oversight during an interview. Additionally, for Resident #54, there was a discrepancy between the POST form and the medical record, where the POST form indicated a different code status than what was documented in the resident's care plan and physician's orders. The Social Worker acknowledged that the POST form reflected the correct wishes of the MPOA, indicating errors in the other documents.
Failure to Address Verbal Abuse Allegations Systematically
Penalty
Summary
The facility failed to develop and implement policies and procedures to prioritize performance improvement activities focusing on resident safety, quality of care, and high-volume or problem-prone areas. This deficiency was identified during a review of eight complaints investigated concurrently with the annual Long-Term Care Survey Process. Five of these complaints were facility-reported incidents involving allegations of staff verbally abusing residents. During an interview, the Regional Director of Operations and the Regional Director of Corporate Operations acknowledged that the Quality Assessment and Assurance (QAA) Committee did not identify or address the pattern of verbal abuse allegations as an area for improvement. The Assistant Director of Nursing and the Infection Preventionist, who attended the QAA Committee meetings, confirmed that each incident was treated on a case-by-case basis and was not officially addressed at a systems level or within the QAA Committee meetings.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, specifically the ice machine in the main dining room. During an observation, it was found that the water drainpipe of the ice machine was improperly connected directly into the sewer pipe without the recommended two-inch air gap. Both the drainpipe and sewer pipe were covered with a black substance. This deficiency was verified by the Director of Dietary, who confirmed the absence of the air gap and the presence of the black substance on the pipes.
Ineffective Pest Control Program in Kitchen Area
Penalty
Summary
The facility failed to implement an effective pest control program, as evidenced by the presence of ants in the kitchen area. During a kitchen inspection, ants were observed in the dishwashing room. The Maintenance Director confirmed the presence of ants and stated that the facility does not have an exterminator spray for roaches or ants, relying instead on staff to spray if insects are observed. The exterminator only places bait in traps outside, which is insufficient for addressing the ant issue inside the facility. This deficiency has the potential to affect all 88 residents residing in the facility.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Notification of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) in a timely manner for a resident whose Medicare Part A services had ended. The resident continued to stay in the facility after the end of her skilled Medicare coverage, which concluded on January 11, 2024. However, the NOMNC and SNF ABN were not issued until January 15, 2024, four days after the coverage had ended, and were signed by the resident's representative on January 17, 2024. According to the instructions for the NOMNC, it must be delivered at least two calendar days before the end of Medicare-covered services, regardless of whether the beneficiary agrees with the termination of services. The SNF ABN is required to be issued prior to providing care that Medicare usually covers but may not pay for due to reasons such as the care not being medically reasonable and necessary or being considered custodial. The Business Office Manager confirmed that the required two-day notice was not given to the resident.
Failure to Report Neglect of Resident Left Unattended
Penalty
Summary
The facility failed to implement its abuse policies for reporting neglect, affecting one resident. The resident, who is unable to propel her wheelchair independently due to tremors, reported being left outside alone in the courtyard multiple times after smoke breaks. On one occasion, she was left in the hot sun for two hours without a way to notify staff. The facility's grievance forms and medical records corroborate these incidents, with staff leaving the resident unattended despite her inability to reenter the facility on her own. The facility's policy required that all alleged violations involving neglect be reported to the appropriate state agencies, but the Administrator did not consider leaving the resident outside unattended as neglectful and thus did not report the incidents. Observations of the courtyard revealed no call lights or push buttons for residents in wheelchairs to use, further highlighting the lack of support for residents with mobility issues. The resident's care plan indicated she required assistance for mobility, yet this was not consistently provided, leading to her being left unattended outside.
Neglect and Verbal Abuse Incidents in LTC Facility
Penalty
Summary
The facility failed to appropriately respond to allegations of neglect and verbal abuse involving two residents. Resident #29 reported being left outside alone in the courtyard multiple times after smoke breaks, despite being unable to propel her wheelchair independently due to tremors. The resident was left in the hot sun for extended periods without a means to notify staff for assistance. The facility's grievance forms and medical records corroborated these incidents, yet the facility administrator did not consider the situation neglectful and did not investigate the incidents. In another case, Resident #86 reported verbal abuse and threats from another resident, Resident #11. Despite the resident's complaints and visible distress, the facility's response was inadequate. The staff offered a room change to Resident #86, which she refused, questioning why she should be the one to move. The facility failed to report the abuse to the appropriate state agency, OHFLAC, and did not implement effective interventions to prevent recurrence or provide adequate psychosocial support to the affected resident. The facility's failure to investigate and report these incidents, as well as to implement preventive measures, highlights significant deficiencies in handling resident safety and well-being. The lack of thorough investigation and appropriate response to the allegations of neglect and abuse had the potential to affect other residents in the facility, as evidenced by the facility's inadequate use of current guidelines for reporting and addressing such incidents.
Failure to Notify Residents and Ombudsman of Transfers
Penalty
Summary
The facility failed to provide the required written Notice of Transfer or Discharge to residents or their representatives and did not notify the Long-Term Care Ombudsman of hospital transfers for two out of three residents reviewed. Resident #191 was transferred to the hospital, but there was no evidence in the medical record that a written notice was provided to the resident or their representative, nor was the Ombudsman notified. The Medical Records Director confirmed the absence of documentation for this transfer. Similarly, Resident #34 was discharged to the hospital, and the medical record lacked documentation of the Notice of Transfer or Discharge being provided to the resident's representative or the Ombudsman. The Social Worker verified the absence of this documentation. Additionally, Resident #39 was hospitalized, and the medical record did not contain evidence of the required notifications. The Social Worker confirmed that neither the resident's representative nor the Ombudsman was notified of the discharge.
Failure to Provide Bed Hold Notices and Transfer Notifications
Penalty
Summary
The facility failed to provide necessary notifications and documentation related to bed hold policies and transfer notices for residents who were transferred to hospitals. Specifically, Resident #34 was discharged to the hospital, but there was no documentation that the Notice of Transfer or Discharge was provided to the resident's representative, nor was the Ombudsman notified. This was confirmed by the Social Worker during an interview. Similarly, Resident #191 was transferred to the hospital, and the facility could not produce evidence that a Bed Hold notice had been issued, as confirmed by the Medical Records Director. Additionally, Resident #39's medical record review revealed a lack of documentation that the Notice of Bed Hold Policy was provided to the resident's representative during a hospitalization. The Social Worker confirmed the absence of this documentation. These deficiencies were identified during the annual Long-Term Care Survey Process, affecting two out of three residents reviewed under the hospitalization pathway, with a facility census of 86.
Failure to Update PASARR with New Mental Health Diagnoses
Penalty
Summary
The facility failed to update the Pre-Admission Screening and Resident Review (PASARR) for a resident after they were diagnosed with major mental disorders post-admission. The resident was initially admitted to the facility and later diagnosed with major depressive disorder and bipolar disorder. Despite these diagnoses, the PASARR submitted did not reflect these new mental health conditions. This oversight was confirmed during an interview with the social worker, who acknowledged the absence of the updated diagnoses on the PASARR.
Failure to Obtain Ordered Laboratory Services
Penalty
Summary
The facility failed to obtain laboratory services as ordered by the physician for a resident, leading to a deficiency. Resident #41, who has Diabetes Mellitus II, had a physician's order for Novolog Injection Solution to be administered according to a sliding scale and to notify the medical doctor if blood sugar levels were below 60 or above 450. Additionally, there was an order for a Complete Blood Count (CBC) and Glycated hemoglobin (HgbA1c) test every six months, dated 08/09/23. Upon review of the medical records on 06/04/24, the surveyor could not find the most recent results of these tests. An interview with the Assistant Director of Nursing (ADON) confirmed that the CBC and HgbA1c tests had not been obtained as per the physician's orders.
Ceiling Damage in Resident Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by the condition of the ceiling in Room B6. During an observation, a resident pointed out several brown spots on the ceiling directly above her bed, with the largest spot being the size of a plate. Additionally, there was a plate-sized hole in the ceiling from which drywall contents were extruding. The Maintenance Supervisor later confirmed that the damage was due to water issues, indicating a lack of timely maintenance and repair in the facility.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information in a prominent place readily accessible to residents and visitors on a daily basis. On 06/03/24 at 7:04 AM, an observation revealed that the posted nurse staffing information was dated for 05/31/24, indicating that the postings for 06/01/24, 06/02/24, and 06/03/24 were not updated. During an interview conducted at 7:05 AM on the same day, the Medical Records Director confirmed the failure to provide the correct postings for the specified dates.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
