Peterson Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheeling, West Virginia.
- Location
- 20 Homestead Avenue, Wheeling, West Virginia 26003
- CMS Provider Number
- 515002
- Inspections on file
- 25
- Latest survey
- October 8, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Peterson Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Staff failed to identify, report, and investigate repeated incidents of inappropriate resident behavior and family-reported concerns about pain management. Despite ongoing documentation and staff awareness of a resident entering female residents' rooms and another resident's unmanaged pain, the facility did not log or report these events to authorities as required by policy.
Multiple incidents occurred where a resident repeatedly entered female residents' rooms without permission, engaged in inappropriate touching, and used verbal insults toward other residents. Staff and social services were aware of these behaviors, but interventions were limited to redirection and verbal warnings, with no evidence of thorough investigation or protective measures for affected residents. In several cases, residents were not interviewed to ensure their safety, and incidents of verbal abuse were not recognized or reported as abuse, resulting in a lack of appropriate action to prevent recurrence.
A resident who experienced sleep disturbances due to a noisy roommate reported her concerns and requested a room change to both nursing staff and the DON. However, the facility did not document the grievance in its logs, and the DON was unaware of the request, citing documentation issues.
A resident repeatedly engaged in sexually inappropriate behaviors toward female residents, including entering their rooms without permission and making inappropriate comments. Despite ongoing documentation of these incidents by staff and social services, the care plan was not updated to include new interventions, and the facility did not report the incidents as abuse or take adequate steps to prevent recurrence.
A resident on anticoagulant therapy experienced a prolonged nosebleed that was not promptly or properly assessed or treated by licensed nursing staff. Facility records showed no documentation of a change-in-condition assessment, vital signs, or provider notification during the episode, and no new physician orders were obtained. Staff interviews indicated short staffing and lack of appropriate follow-up, leading the resident's family to contact EMS for hospital transfer.
A resident with multiple pain-related diagnoses and under hospice care did not receive PRN pain medication in a timely manner as ordered by the physician and outlined in the care plan. Interviews with the resident and family, along with record review, confirmed delays in pain medication administration, and the DON acknowledged the failure to provide prompt pain relief.
A resident's bathroom was found with a pool noodle and foam taped to the water pipe and flush handle, which could not be properly sanitized. The DON confirmed these items were installed for a previous occupant and acknowledged the infection control issue, resulting in a failure to maintain a sanitary environment.
The facility did not ensure that the most recent survey results were prominently displayed and accessible to residents and the public. During a resident council meeting, several residents, who were cognitively intact, expressed uncertainty about the location of the survey results. The Administrator confirmed that the notice of availability was not posted in prominent areas.
The facility failed to ensure grievance forms were accessible to all residents, particularly those in wheelchairs, hindering their ability to file grievances anonymously. A resident confirmed they could not reach the forms or submission box without standing, and a social worker acknowledged this issue, noting residents would need assistance to obtain a form.
The facility failed to maintain safe water temperatures, with surveyors finding temperatures as high as 126°F in resident-accessible areas, posing a burn risk. The Maintenance Supervisor claimed weekly checks showed temperatures averaging 113°F, but survey findings contradicted this. The Nursing Home Administrator confirmed responsibility for maintaining safe temperatures.
The facility failed to serve food at an appetizing temperature during a lunch meal service. A food truck with lunch trays was brought out, and staff began delivering trays. A surveyor requested a CNA to select a tray for temperature testing, revealing that the food was below the desired 120 degrees Fahrenheit. A dietary aide confirmed the temperatures were inadequate.
The facility failed to maintain ice machines in a safe condition, affecting residents' nutrition and food-related activities. During a tour, it was found that ice machines had drainpipes touching the floor and lacked required air gaps and filters. The Maintenance Director confirmed these deficiencies.
The facility failed to maintain accurate and complete medical records for several residents, including incomplete or conflicting POST forms, incorrect documentation dates, and non-compliance with physician orders for dialysis care. These deficiencies were identified through record reviews and staff interviews, highlighting issues in documentation and adherence to medical directives.
A resident was unable to reach her call light, which was wrapped around her bedrail, causing discomfort as she sat in a wheelchair. A nurse aide acknowledged the issue and, with another staff member, assisted the resident using a Hoyer lift.
A facility failed to update a resident's PASSAR to reflect new diagnoses of unspecified psychosis and hallucinations. The PASSAR inaccurately marked 'None' for current diagnoses and listed dementia as the primary diagnosis, despite the resident's updated medical condition. This was confirmed by a social worker during an interview.
The facility failed to ensure accurate PASARR documentation for two residents, leading to deficiencies in capturing pre-admission diagnoses. A resident was admitted with Bipolar and Major Depression Disorder, but the PAS did not reflect these conditions. Another resident's PASARR marked Major Depression but failed to include Bipolar Disorder, which was present upon admission. Staff acknowledged these oversights, and no new PASARRs were completed to correct them.
A facility failed to create a comprehensive care plan for a resident with schizoaffective disorder. Despite the diagnosis being present upon admission, the care plan did not address this condition. The absence of a specific care plan was confirmed by the DON during an interview.
The facility failed to update care plans for three residents, leading to inaccuracies. A resident's care plan incorrectly listed a urinary catheter as a personal preference instead of urinary retention. Another resident's plan included antipsychotic medication and behavior monitoring, despite no prescription or behaviors. A third resident's plan mentioned peg tube care, although the tube had been discontinued. These issues were confirmed by the DON and Administrator.
The facility failed to follow physician's orders for two residents, resulting in missing documentation for medication administration and behavior monitoring. One resident had missing entries for behavior and side effect monitoring, while another had omissions for multiple medications and behavior tracking. The DON confirmed these deficiencies.
The facility failed to date insulin upon opening for a resident and did not dispose of expired insulin for another resident, as observed during a medication cart tour. The facility's policy requires multi-dose vials to be dated and discarded within 28 days, which was not followed. These deficiencies were confirmed by an RN and the DON.
A facility failed to maintain proper infection control for foley catheter care when a resident's urinary catheter drainage bag was observed touching the floor. A nurse aide confirmed the issue, and the DON was notified.
A resident with dementia was found in a sexually inappropriate situation with another resident, but the facility failed to recognize it as abuse due to the perpetrator's cognitive impairment. The incident was not properly investigated, and care plans were not updated to address the behavior or potential trauma. This oversight placed other residents at risk, leading to an immediate jeopardy situation.
A resident was administered Haldol without a physician's order after exhibiting aggressive behavior, leading to a deficiency in medication administration protocols. The nurse involved could not report the dose given and discarded the medication bottle, and there was no active order for the medication at the time of administration.
A resident suffered a burn injury after spilling reheated hot coffee on herself while in bed, highlighting the facility's failure to ensure a safe environment. The care plan required the resident to be seated when consuming hot liquids, and the temperature should not exceed 180 degrees. Staff interviews revealed a lack of awareness of the facility's policy on reheating food and liquids, with only one staff member educated on hot liquid safety after the incident.
A resident sustained a burn injury after the facility failed to implement a comprehensive care plan designed to minimize the risk of injury from hot liquids. Despite having a care plan that required the resident to be out of bed and liquids not to exceed 180 degrees, the resident was served reheated coffee while in bed, leading to a spill and subsequent burn. The incident revealed a pattern of non-compliance with the care plan, as the resident had previously suffered similar injuries.
A facility failed to report an alleged resident-to-resident sexual abuse incident to the appropriate state agency. The incident involved a resident being observed inappropriately on top of their roommate, attempting to remove the roommate's gown and brief. Although the facility's policy requires reporting to the State Agency and APS, the report was only made to APS and the Long-Term Care Ombudsman. The Administrator acknowledged this oversight during an interview.
The facility did not update the care plans for two residents after an incident of sexual abuse. A resident was found engaging in inappropriate sexual behavior with their roommate, but their care plan did not address these behaviors. Additionally, the roommate's care plan lacked measures for potential trauma. The Administrator and DON confirmed the care plans were not revised.
Failure to Identify, Report, and Investigate Abuse and Neglect
Penalty
Summary
The facility failed to identify, report, and investigate multiple incidents of potential abuse, neglect, and mistreatment involving two residents. For one resident, there were repeated documented instances over a period of more than six months where the resident entered female residents' rooms, sometimes while they were sleeping, and engaged in inappropriate behaviors, including verbal altercations and physical contact. Staff notes and interviews confirmed that these behaviors were known to staff, including the DON, social workers, and nursing staff, who routinely redirected the resident but did not initiate a formal investigation or report the incidents to the appropriate authorities. The care plan for this resident acknowledged inappropriate sexual behaviors, but interventions were limited to redirection and monitoring, without escalation or reporting as required by policy. In addition, the facility failed to recognize and report allegations of neglect related to pain management for another resident. Family members made multiple complaints to staff and the DON regarding the resident's unmanaged pain and delayed administration of PRN medication. Documentation showed that these complaints were not entered into the facility's grievance or concern logs, nor were they reported to state agencies as required by the facility's own abuse and neglect policy. Staff interviews confirmed awareness of the complaints but acknowledged that no formal reporting or logging occurred. The facility's inaction included not interviewing potentially affected residents, not investigating the incidents, and not addressing the issues in Quality Assurance meetings. The Administrator confirmed that the facility did not consider the incidents reportable because no formal complaints were received from residents, despite clear evidence of repeated inappropriate behaviors and family-reported concerns. The failure to report, investigate, and implement interventions to prevent further abuse and neglect constitutes a deficiency in the facility's responsibility to protect residents from abuse, neglect, and mistreatment.
Failure to Investigate and Prevent Resident-to-Resident Abuse and Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of verbal and sexual abuse, did not implement interventions to prevent further abuse during ongoing investigations, and did not take appropriate corrective actions to ensure that abuse or mistreatment would not recur. Several residents were involved in incidents where one resident repeatedly entered female residents' rooms without permission, including while they were sleeping. Staff redirected the resident and notified supervisors, but the behavior continued over several days. Documentation shows that social services and nursing staff were aware of the ongoing incidents, but interventions were limited to redirection and verbal warnings, with no evidence of more robust measures to prevent recurrence during the investigation period. In one case, a resident with Huntington's Disease, mood and anxiety disorders, depression, and legal blindness reported that another resident attempted to be sexual with her by touching her arms and legs. She called 911 and was taken to the hospital, but assessments found no physical evidence of abuse. The resident's mother, who is her MPOA, confirmed her daughter's paranoia and blindness and was aware of the incident. The facility submitted an initial report to the state agency and conducted interviews, but the investigation was deemed inconclusive, and there was no documentation of further protective interventions for the resident or others potentially at risk. Other residents were also involved in incidents where the same resident attempted to enter their rooms or engaged in inappropriate verbal exchanges. In several cases, there was no documentation that the facility interviewed the potentially affected residents to ensure their safety or freedom from abuse. Additionally, an incident involving verbal abuse between residents was logged as a grievance but not recognized or reported as abuse, and no investigation or action was taken to prevent recurrence. The facility's response to these incidents lacked thorough investigation, timely interventions, and appropriate follow-up to protect residents from further abuse or mistreatment.
Failure to Document and Address Resident Grievance
Penalty
Summary
The facility failed to document and promptly address a resident's grievance regarding a room change request. The resident reported experiencing difficulty sleeping due to a noisy roommate and stated that she had communicated her concerns and request for a room change to both a nurse and the DON in late August. Despite this, a review of the facility's Concern/Grievance logs for the relevant period showed no record of the resident's complaint. During an interview, the DON confirmed she was unaware of the resident's request and acknowledged ongoing issues with staff documentation of grievances.
Failure to Update Care Plan and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to revise and update a resident's care plan and implement effective interventions to ensure that residents were free from abuse. Over a period of more than six months, staff and the social worker documented multiple incidents of a resident engaging in sexually inappropriate behaviors, including entering female residents' rooms without permission, making inappropriate comments, and touching other residents inappropriately. Despite these repeated incidents, the facility did not identify or report these actions as abuse, nor did it take sufficient action to prevent further occurrences. Progress notes and grievance logs revealed that staff repeatedly redirected the resident and discussed the inappropriate behaviors with him, but the care plan was not updated to reflect new interventions or strategies to address the ongoing issues. The care plan initially included general interventions such as administering medications and approaching the resident calmly, but these were not revised in response to the continued incidents. The facility also failed to report the incidents to the appropriate authorities, such as OHFLAC and APS, as required. Interviews with staff and administration confirmed that the care plan had not been updated to address the resident's behaviors and that there was a lack of clarity regarding reporting responsibilities. The social worker and DON acknowledged awareness of the complaints and incidents but did not ensure that the care plan was revised or that effective measures were implemented to protect other residents from further abuse.
Failure to Assess and Intervene for Acute Bleeding in Anticoagulated Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a licensed nurse completed a timely assessment and intervention in response to an acute change in condition for a resident at high risk for bleeding due to anticoagulant therapy. The resident, who had a history of acute respiratory failure, morbid obesity, muscle weakness, and atrial fibrillation, was prescribed Rivaroxaban (Xarelto), increasing her risk for bleeding. On the day of the incident, the resident experienced a prolonged nosebleed shortly after receiving her anticoagulant medication. Staff provided only basic first aid measures, such as ice and washcloths, and there was no evidence of a licensed nurse performing a change-in-condition assessment or documenting vital signs during the episode. The facility's records lacked contemporaneous nursing documentation or assessment corresponding to the family-reported episode of active nasal bleeding. There was no documentation of a change-in-condition assessment, vital signs, or licensed-nurse follow-up related to the bleeding event. Additionally, the facility failed to reassess and document the resident's oxygenation status following the onset of the nosebleed, despite the resident's history of respiratory failure and current oxygen therapy. No new physician orders were entered, and there was no evidence of provider notification or new treatment orders related to the acute event. Interviews with staff revealed that the facility was short-staffed on the evening of the incident, and nurses were pulled from other wings to provide coverage. The administrator and nursing staff were unable to provide documentation of any nursing assessment, physician notification, or change-of-condition report related to the incident. The resident's family ultimately contacted emergency medical services to transfer the resident to the hospital for evaluation, as they were dissatisfied with the care provided during the episode.
Failure to Provide Timely PRN Pain Management
Penalty
Summary
The facility failed to provide timely PRN pain management for a resident with significant medical needs, including muscle spasms, lumbar and thoracic compression fractures, diabetes, and right hip pain. The resident was under hospice care with a terminal prognosis and had physician orders for Morphine Sulfate oral solution to be administered every hour as needed for shortness of breath or pain. Interviews with the resident and family members revealed that the resident experienced delays in receiving pain medication, with one instance where the medication was not administered for over an hour after being requested. Documentation confirmed that the PRN pain medication was administered late on at least one occasion. The resident's care plan emphasized the importance of timely pain control and encouraged the resident to request medication before pain became severe. Despite this, both the resident and family reported repeated delays in pain medication administration, and the Director of Nursing acknowledged that the PRN pain medication was not given promptly upon request. These findings indicate that the facility did not follow physician orders or the resident's person-centered care plan regarding timely pain management.
Improperly Covered Bathroom Fixtures Create Infection Control Deficiency
Penalty
Summary
During an interview and observation in a resident room, a bathroom door was found open, revealing a 'pool noodle' taped with orange tape along the entire length of the water pipe leading to the commode, and the flush handle was also covered with foam and tape. A resident occupying the room stated that these items were present upon their arrival. The DON confirmed that these modifications had been installed for a previous occupant and acknowledged that they constituted an infection control issue, as the materials could not be properly sanitized. This situation demonstrated a failure to maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to ensure that the most recent survey results were located in prominent areas and readily accessible to residents and the public. During a resident council meeting, several residents, including the Resident Council President, expressed uncertainty about the location of the survey results, despite being aware of their availability. These residents were cognitively intact, as confirmed by their most recent MDS records. The facility's Administrator acknowledged that the notice of the availability of the survey results was not posted in prominent areas, making it inaccessible to all residents.
Inaccessible Grievance Forms for Wheelchair-Bound Residents
Penalty
Summary
The facility failed to ensure that grievance forms were accessible to all residents, particularly those confined to wheelchairs, thereby impeding their ability to file grievances anonymously. During an observation upon entrance to the facility, it was noted that the grievance forms were placed too high for residents who could not stand, making it difficult for them to obtain a form without assistance. This issue was specifically identified for Resident #40, who confirmed their inability to reach the forms or the box provided for submitting grievances without standing up from their wheelchair. A staff interview with Social Worker #147 corroborated this finding, acknowledging that residents would need to ask for assistance to obtain a form, thus compromising their ability to file grievances anonymously.
Unsafe Water Temperatures Pose Burn Risk
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding water temperatures in various areas accessible to residents. During a survey, it was discovered that water temperatures in the facility exceeded safe levels, with temperatures recorded as high as 126 degrees Fahrenheit in some locations. This poses a significant risk of third-degree burns to residents, as water temperatures above 120 degrees Fahrenheit can cause severe burns within minutes. The surveyors noted that the water temperature in a resident's room and multiple shower rooms were above the recommended safe levels. The Maintenance Supervisor indicated that water temperatures were tested weekly and typically averaged around 113 degrees Fahrenheit. However, the survey findings contradicted this, showing higher temperatures that could potentially harm residents. The Nursing Home Administrator acknowledged the issue and confirmed that the maintenance director was responsible for ensuring water temperatures were maintained at 110 degrees Fahrenheit or below. The deficiency was identified as having the potential to negatively affect more than a limited number of residents, given the facility's census of 132 residents.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to serve food to residents at an appetizing temperature, as observed during a lunch meal service on Wing 1. A food truck containing lunch trays was brought out of the kitchen, and staff began delivering trays to residents' rooms. At 1:03 PM, with four trays remaining on the cart, a surveyor requested that a CNA select a tray that would be served last. The CNA selected a tray for a resident who was not present, as she was going out to eat with a family member. A dietary aide was called to measure the temperature of the selected tray, which revealed that the hamburger was at 116.5 degrees Fahrenheit, carrots at 112.2 degrees Fahrenheit, and ham at 104.0 degrees Fahrenheit. The dietary aide confirmed that these temperatures were below the desired 120 degrees Fahrenheit for hot food at the point of delivery.
Ice Machine Safety Deficiency
Penalty
Summary
The facility failed to maintain the ice machines in a safe operating condition, which could potentially affect all residents who receive nutrition from the kitchen and those participating in food-related activities. During a tour with the Maintenance Director, it was observed that the ice machines in the kitchen area had a drainpipe running on the floor to a drain, and the nutrition rooms on units one and three lacked the required air gap on the ice machine drains, with the drainpipes touching the drains. Additionally, units one, five, and six were found to have no required filter on the ice machines. The Maintenance Director confirmed that the drainpipes should not be touching the floor or drain and that all ice machines should have a filter.
Deficiencies in Medical Record Accuracy and Compliance
Penalty
Summary
The facility failed to maintain accurate and complete medical records for seven residents, leading to several deficiencies. For Resident #3, the West Virginia Physicians Orders for Scope of Treatment (POST) form was incomplete as the resident's signature was not dated. Resident #17's POST form had conflicting selections in section B, where both selective treatments and comfort-focused treatments were chosen, contrary to the instructions to select only one. Resident #280's record showed a verbal consent from the Medical Power of Attorney (MPOA) was obtained, but the required signature was not collected in a reasonable time frame. Resident #128's transfer form contained an incorrect date, indicating a discrepancy in documentation. Additionally, Resident #71 and Resident #123 both had POST forms that were signed but not dated, rendering them legally invalid. For Resident #75, there was a failure to adhere to physician orders regarding dialysis care, as blood pressures were documented as being taken from the right arm, despite orders prohibiting such actions. This was confirmed by the resident, who stated he would not allow blood pressures to be taken from his right arm, indicating a lack of compliance with the specified medical directives.
Resident's Call Light Out of Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident by ensuring the call light was within reach. During an observation, the resident was found sitting in a wheelchair in her room, expressing discomfort and a desire to go to bed. When asked if she could reach her call light, the resident attempted to do so but was unable to reach it as it was wrapped around her bedrail behind her. A nurse aide entered the room after the call light on the opposite side was activated and acknowledged that the resident did not have her call light. The aide handed the call light to the resident and assured her that assistance would be provided shortly. The aide returned with another staff member, and they assisted the resident with her needs using a Hoyer lift.
Failure to Update PASSAR with New Diagnosis
Penalty
Summary
The facility failed to update the Pre-Admission Screening and Resident Review (PASSAR) for a resident to reflect a new diagnosis after admission. Specifically, the PASSAR for Resident #13, dated 04/05/24, did not include the resident's current diagnoses of unspecified psychosis and hallucinations, which were identified on 02/20/24. Instead, the PASSAR inaccurately marked 'None' for current diagnoses and listed dementia as the primary diagnosis. This discrepancy was confirmed during an interview with Social Worker #147, who acknowledged that the PASSAR did not reflect the resident's updated medical condition.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASARR) documentation for two residents, leading to deficiencies in capturing pre-admission diagnoses. Resident #125 was admitted with diagnoses of Bipolar and Major Depression Disorder, but the PAS completed prior to admission did not reflect these conditions, marking 'NONE' under relevant sections. The Director of Social Services confirmed that these diagnoses were not captured, and a new PAS was not completed. Similarly, Resident #67's PASARR, dated 12/06/22, marked Major Depression but failed to include the diagnosis of Bipolar Disorder, which was present upon admission on 12/02/21. The Social Worker acknowledged the oversight and confirmed that no new PASARR was completed to reflect the bipolar diagnosis after admission.
Lack of Comprehensive Care Plan for Schizoaffective Disorder
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident diagnosed with schizoaffective disorder. Upon review of the medical records, it was found that the resident had this diagnosis upon admission, yet the current care plan did not address the disorder. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan specifically for schizoaffective disorder for the resident in question.
Care Plan Inaccuracies for Three Residents
Penalty
Summary
The facility failed to appropriately revise care plans for three residents, leading to discrepancies in their medical records. For Resident #128, the care plan inaccurately listed the need for a urinary catheter as a personal preference, while the correct diagnosis was urinary retention. This error was confirmed by the Director of Nursing (DON) during the survey. Resident #90's care plan incorrectly included focus areas for antipsychotic medication and behavior monitoring, despite the resident not being prescribed such medication or exhibiting any behaviors. The DON acknowledged that the care plan should have been updated to reflect the resident's current status. Resident #86's care plan included interventions for a peg tube, although the resident no longer had one, as the orders for the peg tube had been discontinued months prior. Both the DON and the Administrator confirmed that the care plan still listed peg tube care, despite its discontinuation. These inaccuracies in the care plans were identified during the survey process, affecting three out of 32 sampled residents in a facility with a census of 132.
Failure to Follow Physician's Orders for Medication and Monitoring
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication administration and monitoring for two residents, leading to deficiencies in care. For Resident #13, a review of the Medication Administration Record (MAR) on February 13, 2025, revealed missing documentation for behavior and side effect monitoring on February 4, 2025. Specifically, there were blanks for tracking physically abusive behavior, antianxiety and antipsychotic medication side effects, socially inappropriate or disruptive behavior, and verbally abusive behavior. The Director of Nursing (DON) confirmed these omissions. Similarly, for Resident #58, a review of the MAR on February 13, 2025, showed missing entries for medication administration and monitoring on September 21, 2024. The omissions included several medications such as Atorvastatin, Famotidine, Melatonin, Metformin, Seroquel, and Tylenol Extra Strength. Additionally, there was a lack of documentation for behavior monitoring, including refusal of care, depression, insomnia, pain score, and side effect tracking for antidepressants and antipsychotics. The DON also confirmed these missing entries.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to adhere to its medication labeling and storage policy, resulting in deficiencies related to the handling of insulin for two residents. During a tour of the medication cart on the 800 wing, it was observed that insulin glargine for Resident #3 was not dated upon opening, and Novolog insulin for Resident #18 was expired, having surpassed the 28-day usage period after opening. These findings were confirmed by RN #119. A review of the facility's policy on medication labeling and storage revealed that multi-dose vials should be dated upon opening and discarded within 28 days. The Director of Nursing confirmed that the insulin should have been dated and discarded according to the policy.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain an appropriate infection control program for foley catheter care. During an observation, a resident's urinary catheter drainage bag was found touching the floor. A nurse aide confirmed the observation and acknowledged that the drainage bag should not be in contact with the floor. The Director of Nursing was informed of the situation and confirmed the improper placement of the drainage bag.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident #137, who has a diagnosis of dementia and other mental health disorders, was found on top of Resident #39, attempting to remove his clothing in a sexually inappropriate manner. Despite the incident being observed by staff, the facility did not recognize it as an occurrence of sexual abuse, citing Resident #137's lack of capacity for intent due to cognitive impairment. The facility's investigation into the incident was inadequate, as it did not substantiate the occurrence of abuse. The social worker involved in the investigation acknowledged that the resident's severe cognitive impairment made it unlikely for him to express how the incident affected him. However, the facility did not update the care plans for either resident to address the inappropriate sexual behavior of Resident #137 or the potential trauma experienced by Resident #39. The facility's failure to follow its abuse policy and recognize the incident as sexual abuse placed other residents at risk. The state agency determined this was an immediate jeopardy situation, highlighting the facility's deficient practice in identifying potential psychosocial harm and failing to classify the incident as sexual abuse, regardless of the residents' capacity.
Unauthorized Administration of Haldol to Resident
Penalty
Summary
The facility failed to keep a resident free from chemical restraint when an antipsychotic medication, Haldol, was administered without a physician's order. During a complaint survey, it was found that Resident #38 was given an intramuscular injection of Haldol after exhibiting aggressive behavior, including screaming and chasing staff. The nursing progress notes indicated that the resident was held down and given the medication, which was not authorized by a physician at the time of administration. Interviews conducted during the investigation revealed that the nurse who administered the Haldol was unable to report the dose given and had discarded the medication bottle. The nurse provided the medication from a zip lock bag, and there was no active physician order for Haldol on the date it was administered. The nurse practitioner confirmed that no order for Haldol was authorized until the day after the resident was taken to the hospital. The incident put the resident at risk for serious harm, as the medication was administered without proper authorization. The facility was notified of the immediate jeopardy, and the lack of an active order for the medication was identified as the cause of the deficiency. The resident's aggressive behavior and the subsequent unauthorized administration of Haldol highlighted a significant lapse in following medication administration protocols.
Failure to Ensure Safe Handling of Hot Liquids
Penalty
Summary
The facility failed to ensure a safe environment for its residents, specifically concerning the handling of hot liquids. Resident #27 suffered a burn injury after spilling reheated hot coffee on herself while in bed. The incident was documented on 10/30/23, and it was noted that the coffee was served in a regular cup without a lid or straw, contrary to the care plan interventions. The care plan had specified that the resident should be in a sitting position when consuming hot liquids and that the temperature of liquids should not exceed 180 degrees. Interviews with staff revealed a lack of awareness and adherence to the facility's policy and procedures regarding the reheating of food and liquids. Nurse Aide #202, who was involved in the incident, was the only staff member educated on hot liquid safety following the incident. Further interviews with other staff members, including a Registered Nurse, Helping Hands staff, and an LPN, indicated they were unaware of the facility's policy for reheating food and liquids, highlighting a systemic issue in staff training and policy implementation. The facility was notified of the Immediate Jeopardy situation due to the failure to follow the resident's plan of care and the facility's policy, which resulted in the injury. The incident was part of a pattern, as it was revealed that Resident #27 had experienced at least two burns from hot coffee at different times. This deficiency put all residents who consume hot beverages at risk for serious injury, emphasizing the need for comprehensive staff education and adherence to safety protocols.
Failure to Implement Care Plan Results in Resident Burn Injury
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan for one of its residents, resulting in the resident sustaining a burn injury. The resident, identified as Resident #27, had a care plan in place to minimize the risk of injury from hot liquids, which included specific interventions such as ensuring the resident was out of bed and in a sitting position when consuming hot liquids, and that the temperature of liquids should not exceed 180 degrees. However, on the date of the incident, the resident requested her coffee to be reheated and was served while she was in bed, in a regular coffee cup without a lid or straw. This deviation from the care plan led to the resident spilling the hot coffee on herself, causing a burn to her abdomen that required physician intervention. The incident report revealed that the resident had previously sustained at least two burns from hot coffee, indicating a pattern of non-compliance with the care plan. The staff involved, including Nurse Aide #202, did not adhere to the established interventions, contributing to the resident's injury. The care plan, which had been revised multiple times, was not followed during the incident, highlighting a significant lapse in the facility's adherence to the resident's safety protocols. This failure to follow the care plan resulted in actual harm to the resident, necessitating medical treatment for the burn injury.
Failure to Report Resident-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident sexual abuse to the appropriate state agency in a timely manner. The incident involved Resident #137 being observed inappropriately on top of their roommate, Resident #39, attempting to remove the roommate's gown and incontinence brief. This incident was documented by RN Unit Manager #28 and witnessed by CNA #6, who provided a written statement. The facility's policy requires all alleged violations of abuse to be reported to the State Agency and Adult Protective Services (APS), but in this case, the report was only made to APS and the Long-Term Care Ombudsman, omitting the State Agency. The incident occurred in the early hours of 02/14/24, and the facility's failure to report it to the State Agency was acknowledged as an oversight by the Administrator during an interview. The facility's records indicated that the residents were separated following the incident, with Resident #39 being moved to a different wing. Despite these actions, the lack of immediate reporting to the State Agency constitutes a deficiency in adhering to the facility's abuse/neglect policy and state reporting requirements.
Failure to Revise Care Plans After Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to revise the care plans for two residents following an incident of resident-to-resident sexual abuse. Resident #137 was observed by staff engaging in inappropriate sexual behavior with their roommate, Resident #39, including being found naked and attempting to remove the roommate's clothing. Despite these actions, the care plan for Resident #137 did not address the inappropriate sexual behaviors. Similarly, Resident #39's care plan did not include any measures to address potential trauma from the incident. The facility's Administrator and Director of Nursing confirmed that neither resident's care plan had been updated to reflect these needs.
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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