Parkersburg Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parkersburg, West Virginia.
- Location
- 1716 Gihon Road, Parkersburg, West Virginia 26101
- CMS Provider Number
- 515102
- Inspections on file
- 19
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 34 (1 serious)
Citation history
Health deficiencies cited at Parkersburg Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide a safe, clean, and comfortable environment, with issues including broken window blinds, dirty privacy curtains, sticky and unclean floors, and missing or poorly maintained baseboards and paint in resident rooms and bathrooms. These deficiencies were confirmed by facility staff and reported by residents.
Multiple residents experienced neglect, including being told to soil briefs instead of being assisted to the toilet and a fall that was not documented or followed up by staff. These incidents were substantiated through interviews and record reviews, with failures to follow the facility's abuse and neglect policies.
The facility did not thoroughly investigate reportable incidents or submit required five-day follow-up investigation reports to the State Agency for multiple residents. Documentation was missing for staff and resident interviews, evidence of completed investigations, and staff education on emergency procedures. In cases of resident-to-resident abuse and reports of verbal threats, there was no documentation of investigation or follow-up, and required reports were not submitted.
The facility did not consistently provide dependent residents with required assistance for ADLs such as showers, oral care, and grooming. One resident with hemiplegia missed multiple scheduled oral care and bathing sessions, while another resident who preferred showers received only bed baths and was unable to access the shower room due to equipment and space limitations. A third resident, who is blind and requires extensive help, did not receive scheduled hygiene care on several occasions. These deficiencies were confirmed through documentation, resident interviews, and staff observations.
Surveyors observed significant ice and frost buildup on and around the freezer door and fan during a kitchen inspection. A dietary staff member confirmed the findings and indicated the frost developed during frequent access to the freezer. Facility policy requires proper maintenance of kitchen equipment, but this was not followed.
The facility did not ensure that an allegation of verbal abuse involving a resident was reported immediately or within the required two-hour timeframe. Documentation lacked confirmation of when the incident was reported, and some witness statements were collected several days after the event. Staff confirmed the absence of required reporting documentation.
Surveyors identified that two residents did not receive appropriate care: one resident's fall was not documented or treated, and another resident missed multiple physician-ordered medications and essential care tasks over an extended period. These failures were confirmed by staff and had the potential to affect other residents.
Staff failed to use a proper carrier when transporting a full oxygen cylinder, and a resident's fall resulting in injury was not documented or treated at the time of occurrence. The resident, who has Alzheimer's disease and osteoporosis, later returned with a spinal brace and was receiving IV antibiotics for a hip infection.
A resident did not receive their meal in bowls as specified by their dietary order and tray card, with only dessert served in a bowl. This was confirmed by a nursing assistant, despite facility policy requiring assistive devices and utensils to be provided according to the care plan.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment for its residents. In one room, window blinds were found to be broken and missing. In another, a privacy curtain was observed to be dirty with a dark brown substance. Additionally, the floor at the head of a resident's bed, under the tube feeding pole, was dirty and sticky, with evidence of spilled feeding solution and an overall unclean surface. These findings were confirmed by both the Environmental Services Manager and the Administrator, who acknowledged that the issues required attention. A resident reported that her floor and the wall behind her bed were dirty and in need of painting, and that the baseboard in her bathroom was missing, with a poor paint job observed. The state surveyor confirmed the presence of dirty walls, a dirty floor, and missing baseboard in the bathroom. The Regulatory Compliance Officer later verified the dirty wall, scuffmarks, missing paint, and missing baseboard. Documentation reviewed indicated a work order for baseboard replacement had been created, but the baseboard remained missing at the time of the survey.
Failure to Prevent and Document Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect and ensure proper care, as evidenced by multiple substantiated incidents. One resident, who was alert and oriented but lacked capacity for medical decisions, reported that CNAs instructed her to soil her brief instead of assisting her to the toilet, despite her ability to walk to the bathroom with assistance. This allegation was substantiated through resident interviews, although the specific staff member involved could not be identified due to lack of recall by the resident. Another incident involved a resident with Alzheimer's disease and dementia who sustained a fall that was not documented in the medical record. There was no evidence of neuro-checks, treatment, or follow-up after the fall, and the nurse on duty at the time resigned and did not provide a statement. The resident later returned to the facility with a spinal brace and was receiving intravenous antibiotics for a hip infection. The fall and lack of documentation were confirmed by both a CNA and the resident's roommate, who is alert and oriented. A third resident was also found to have experienced neglect, as verified by the facility's investigation. The facility's own Abuse Prohibition Policy requires immediate reporting and thorough documentation of suspected abuse or neglect, but these procedures were not followed in the cases described. The deficiencies were substantiated through interviews, record reviews, and facility investigations.
Failure to Investigate and Report Incidents as Required
Penalty
Summary
The facility failed to thoroughly investigate reportable incidents and submit the required five-day follow-up investigation reports to the State Agency for multiple residents. In several cases, documentation was missing regarding staff and resident interviews, as well as evidence of completed investigations. For example, incident records for one resident did not include documentation of staff interviews or submission of the five-day follow-up report. Another resident's incident file lacked documentation of both staff and resident interviews. Additionally, there was no documentation showing that staff had completed education on handling emergency situations for another resident's incident. Further review revealed that when residents reported experiences of verbal threats or derogatory remarks from other residents, there was no documentation to demonstrate that these responses were investigated or that any follow-up actions were taken. In an incident involving resident-to-resident abuse, while the initial incident was reported to the appropriate agencies and immediate actions were taken, the required five-day follow-up report outlining the investigation, findings, and actions taken was not submitted. These deficiencies were confirmed through interviews with facility leadership and review of facility records.
Failure to Provide ADL Assistance and Honor Resident Preferences for Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including showers, oral care, and grooming, to residents who were dependent on staff for these tasks. For one resident with hemiplegia and hemiparesis, documentation showed that oral care was not provided twice daily as required by facility policy on multiple occasions, and no showers or bed baths were documented on several scheduled days over a 30-day period. There was no documentation of refusals for showers or bed baths, despite the resident's care plan indicating a history of refusal for oral and hair care. Another resident, who required assistance from one to two staff for bathing and a mechanical lift, expressed dissatisfaction with only receiving bed or sponge baths instead of showers, which was her stated preference. Documentation revealed significant gaps in bathing and showering, with extended periods where no hygiene care was recorded. Observations confirmed the resident's hair was uncombed and facial hair was not removed, despite her preference for grooming. Staff interviews revealed that the resident could not access the shower room due to physical limitations and equipment constraints, and her preferences were not honored. A third resident, who was blind and required extensive assistance for ADLs, did not receive scheduled showers or baths on several occasions within a 30-day period. The resident reported not receiving showers or baths as scheduled, and records confirmed that only four out of nine scheduled hygiene sessions were provided. The administrator acknowledged that the frequency of showers and baths was insufficient for this resident.
Failure to Maintain Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain kitchen equipment in safe operating condition, specifically regarding the freezer. During an inspection, a state surveyor observed ice and significant frost accumulation on the right side of the freezer door, as well as small ice drips frozen on the freezer's fan and a large block of ice formed under the freezer fan. A dietary staff member confirmed these findings and stated that there was no frost earlier in the day, suggesting the issue developed during frequent access to the freezer by staff. The facility's policy requires that all kitchen equipment be properly maintained and in safe working order, with the Dining Service Director responsible for ensuring compliance.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving verbal abuse were reported immediately, or within two hours after the allegation was made, as required. Record review of a Facility Reported Incident (FRI) showed that the initial reporting of a verbal abuse allegation lacked confirmation of when the incident was reported, either by fax or email. Witness statements indicated the incident occurred on 11/18/25, but no specific time was documented, and some statements were not collected until six days after the alleged event. During staff interviews, it was confirmed that there was no documentation verifying the date and time the FRI was sent, and no additional information was provided upon request.
Failure to Provide Timely Treatment and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two separate instances. In the first case, a resident with Alzheimer's disease and dementia, who lacked medical decision-making capacity, experienced a fall that was witnessed and reported by both a CNA and the resident's alert and oriented roommate. Despite this, there was no documentation of the fall in the resident's medical record, and no neuro-checks, treatment, or follow-up were performed at the time of the incident. The nurse on duty at the time did not document or address the fall, and subsequently resigned without providing a statement regarding the incident. In the second case, another resident did not receive multiple physician-ordered medications and treatments in a timely manner over the course of November and December. Missed orders included administration of medications via PEG tube for conditions such as seizures, GERD, and hyponatremia, as well as essential care tasks like tracheostomy care, skin care, repositioning, and enteral feeding management. These omissions were confirmed through a Medication Administration Audit Report and acknowledged by the facility administrator as unacceptable. Both deficiencies were identified during the survey process as random opportunities for discovery and had the potential to affect more than a minimal number of residents. The failures involved lack of documentation, failure to follow physician orders, and lack of timely care and treatment for residents with complex medical needs.
Failure to Ensure Safe Oxygen Transport and Timely Fall Documentation
Penalty
Summary
The facility failed to ensure a safe environment for residents by not following established procedures for transporting oxygen cylinders and by failing to document and respond to a resident fall that resulted in injury. Specifically, a nursing assistant was observed carrying a full oxygen tank by hand down the hallway, rather than using a required carrier or stand, in violation of facility policy designed to prevent accidental tipping and potential hazards. This incident was confirmed by both the nursing assistant and the Regulatory Compliance Officer. Additionally, a resident with Alzheimer's disease, dementia, and osteoporosis experienced a fall that was witnessed by his roommate and reported by a certified nursing assistant. However, there was no documentation of the fall in the resident's medical record, nor were any neurological checks, treatments, or follow-up actions recorded at the time of the incident. The nurse on duty during the fall did not document or address the event and subsequently resigned. The resident later returned to the facility with a spinal brace and was receiving intravenous antibiotics for a hip infection.
Failure to Provide Ordered Assistive Eating Devices
Penalty
Summary
The facility failed to provide an assistive device as ordered by the physician for a resident during the dinner meal. The resident's dietary order specified a regular diet with regular texture, standard thin liquids, and that all food should be served in bowls. The resident's tray card also clearly indicated 'FOOD IN BOWLS' in both large and bold print. However, during observation, the resident did not receive their entree or side in bowls, only the dessert was served in a bowl. This was confirmed by Nursing Assistant #9, who acknowledged that the food was not served in bowls as required by the tray ticket and dietary order. The facility's policy stated that assistive devices and utensils should be provided as identified in the individualized plan of care to maintain or improve the resident's ability to eat or drink independently.
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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