Pierpont Center At Fairmont Campus
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairmont, West Virginia.
- Location
- 1543 Country Club Road, Fairmont, West Virginia 26554
- CMS Provider Number
- 515155
- Inspections on file
- 26
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Pierpont Center At Fairmont Campus during CMS and state inspections, most recent first.
A resident’s MDS assessment was inaccurately coded and did not reflect the individual’s documented physical limitations and ADL needs. The care plan showed the resident required dependent or substantial/maximal assistance for bed mobility, toileting, dressing, personal hygiene, and bathing, and had diagnoses including wheelchair dependence, difficulty walking, and hemiplegia/hemiparesis after a cerebral infarction. However, the MDS coded no upper or lower extremity range-of-motion limitations and no use of mobility devices, and the DON acknowledged that this coding did not match the resident’s actual physical status.
Staff failed to ensure appropriate supervision for an incapacitated resident during off-site urology appointments. Records showed the resident had been determined incapacitated and was dependent on staff for ADLs, and a prior visit had resulted in the resident becoming very upset and agitated, after which the urology provider instructed that the resident should not attend appointments alone. Despite this, the resident was transported by the facility van and left in the waiting room without facility staff present, while the van driver waited in the parking lot and family presence was inconsistent. A urology office receptionist confirmed that the resident had been alone in the waiting room on multiple occasions, nonverbal and appearing very sad.
The facility failed to ensure their facility-wide assessment identified necessary staffing levels and training requirements. Sections related to staffing, training, and personnel were incomplete, and there was no evidence of a staffing plan or required competencies. The Administrator acknowledged the gaps but could not provide specific sections addressing these issues.
The facility failed to ensure residents had reasonable and ready access to their personal funds, particularly during evenings and weekends. Residents reported difficulties in obtaining money, leading to canceled outings. Staff interviews revealed limited knowledge and resources for handling such requests outside regular office hours.
The facility failed to ensure clean and safe living areas for residents, with heavily soiled P-Tac vents, poor quality furniture, and damaged ceilings. Additionally, a resident's wheelchair was improperly maintained with clear tape holding a cup holder to the armrest.
The facility failed to ensure that residents were free from unnecessary psychotropic medications used for refusal of care. Two residents were prescribed Abilify for refusal of care, and one resident was observed sleeping frequently, with inconsistent documentation of side effect monitoring. The DON acknowledged the inappropriate use of the medication.
The facility failed to update the PASRR for nine residents diagnosed with serious mental disorders upon admission. Diagnoses such as major depressive disorder, bipolar disorder, and psychosis were not accurately reflected in the PASRR documentation, as confirmed by record reviews and staff interviews.
The facility failed to provide information and offer the RSV immunization to residents as recommended by the CDC. Additionally, the facility did not follow a physician's order regarding insulin administration for a resident, with multiple instances of missing blood glucose level documentation in the MARs.
The facility failed to ensure all vials of multi-use insulin were labeled with the initial date they were opened. This deficiency was observed in three vials found in the medication cart, affecting three residents. RN verified that the insulin vials did not have a date indicating when they were first accessed. The DON was informed of these issues.
The facility failed to store food properly, with breaded fish filets exposed in the walk-in freezer, a trash can placed in front of beverage dispensers, a missing floor tile, and debris on the freezer floor. The Dietary Manager confirmed these issues.
The facility failed to maintain a safe, clean, and comfortable environment for its residents, with issues including heavily soiled P-Tac vents, poor quality furniture, leaking ceilings, and a resident's wheelchair improperly repaired with tape. These deficiencies indicate a lack of effective action by the Quality Assessment and Assurance committee.
The facility failed to maintain an infection prevention and control program, with deficiencies in bedpan storage, laundry services, and ice machine use. Used bedpans were improperly stored, the laundry room lacked proper separation and ventilation, and a resident was seen retrieving ice from a community ice machine despite being instructed not to.
A resident with lactose intolerance received a grilled ham and cheese sandwich despite having cheese listed as a dislike on her meal ticket. The resident's care plan indicated she should be provided with Lactaid milk and monitored for nutritional intake due to multiple health conditions. The meal ticket did not include cheese sandwiches under dislikes, leading to the resident receiving inappropriate food. The DON was informed and acknowledged the oversight.
The facility failed to notify a resident's representative in a timely manner when an antibiotic was ordered to treat a dental abscess. The resident's MPOA was unaware of the infection and treatment, despite noticing bruising and swelling during a visit. The DON confirmed the lack of notification.
The facility failed to ensure a resident's privacy and confidentiality by posting signs with personal care information in her room without family request or care planning. The resident lacked decision-making capacity, and the signs were visible to others.
The facility failed to report a resident fall resulting in serious injuries, including a nasal bone fracture, to the appropriate state agencies within the required two-hour timeframe. The incident was reported four days later due to the absence of both social workers over the Thanksgiving holiday.
The facility failed to notify the State Ombudsman of a resident's transfer to another LTC facility. This was confirmed during a medical record review and an interview with the Licensed Social Worker.
The facility failed to update the PASARR for a resident diagnosed with schizophrenia after admission. The PASARR only indicated a seizure disorder, and the Director of Nursing acknowledged the missing diagnosis.
The facility failed to develop a comprehensive person-centered care plan for discharge planning for a resident. A medical record review revealed that the resident was discharged without a developed care plan, which was confirmed by the LSW.
The facility failed to update a resident's care plan after the removal of an indwelling urinary catheter. This was confirmed during a medical record review and an interview with the DON, highlighting a lapse in maintaining accurate and current care plans.
A resident reported only receiving bed baths despite a preference for showers and a desire to have their hair washed. The DON confirmed the resident was scheduled for baths, but records showed showers were documented. LPN acknowledged documentation issues, and the DON confirmed the discrepancy, constituting a deficiency in care.
A facility failed to ensure a safe environment when a prescribed medication, Amiodarone, was found on the floor in a resident's room. The DON confirmed that nurses must ensure medications are swallowed before documenting administration, indicating a lapse in supervision and medication administration.
The facility failed to ensure residents were free from unnecessary psychotropic medications. One resident had an order for Abilify for refusal of care, which the DON acknowledged was inappropriate. Another resident received Abilify daily without proper side effects monitoring, and the MAR inconsistently documented the resident's condition.
The facility failed to provide appropriate assistive devices to a resident who needed them to eat independently. Despite the care plan indicating the use of a proval cup due to paralysis affecting the left extremities, the resident was not provided with the required cup because they did not like it, as stated by a nurse aide.
The facility failed to maintain accurate medical records for two residents. One resident's preference for showers was not honored, and documentation inaccurately recorded showers instead of bed baths. Another resident's side effects from psychotropic medication were not accurately documented, despite observations suggesting potential side effects. The DON acknowledged these discrepancies.
Inaccurate MDS Coding of Resident Functional Status and Mobility Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure an accurate MDS assessment reflecting a resident’s physical status. Record review for Resident #38 showed an ADL care plan indicating the resident required dependent assistance of two staff for bed mobility; setup and substantial/maximal assist of one for toileting; substantial/maximal assist of one for dressing; partial/moderate to dependent assist of one for personal hygiene; and substantial/maximal assist of one for bathing. The resident’s diagnoses included dependence on a wheelchair, difficulty in walking, and hemiplegia/hemiparesis following a cerebral infarction affecting the right dominant side. Despite these documented functional limitations and care needs, the MDS with an ARD of 11/11/25 was coded in Section GG0115 as having 0 upper and lower extremity limitations in range of motion, and Section GG0120 as using no mobility devices. In an interview, the DON confirmed that the MDS coding was incorrect based on the resident’s physical status. This failed practice was identified as a random opportunity for discovery and was determined to have the potential to affect a limited number of residents during the complaint survey, with a facility census of 108 and the deficiency specifically involving Resident #38.
Failure to Supervise Incapacitated Resident During Off-Site Urology Appointments
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice by not ensuring supervision for an incapacitated resident during out-of-facility urology appointments. Record review showed that the resident had a Physician's Determination of Capacity form indicating incapacity and a care plan documenting dependence on staff for ADLs including bathing, grooming, dressing, eating, mobility, transfers, locomotion, and toileting due to limited mobility. A general patient note documented that during a prior urology visit, the resident became very upset, agitated, and destructive when required to wait, and the urology provider reported that the resident was not to come to appointments alone. Despite this, documentation showed that the resident had multiple subsequent urology appointments to which he was transported by the facility van. Interviews further confirmed that the resident was left unsupervised at these appointments. The resident’s health care surrogate stated that facility staff leave the resident at appointments without anyone from the facility supervising him, particularly at the urology office, and that he is left sitting in the waiting room. The activity assistant/van driver reported that for residents without capacity, an aide typically accompanies them if family cannot come, but in this case, the driver took the resident inside the urology office and then waited in the van in the parking lot, noting that the resident’s son was supposed to come but was only present once or twice. A receptionist at the urology office stated that, during the time she had worked there, the resident was definitely alone in the waiting room on at least two occasions, that he did not talk, and that he sat there looking very sad.
Incomplete Facility-Wide Assessment on Staffing and Training
Penalty
Summary
The facility failed to ensure their facility-wide assessment identified the necessary staffing levels and training requirements to provide adequate care and services for residents. During a review of the Facility Assessment, it was found that sections related to staffing, training, and personnel were incomplete. Specifically, the sections meant to document the total number, average, and range of staff required to meet resident needs were left blank. Additionally, there was no evidence that the facility identified the types of staff members, healthcare professionals, and medical practitioners needed to support and care for residents. The facility also did not describe their staffing plan or the training and competencies required for staff to meet the needs of the resident population. In an interview, the Administrator acknowledged that the facility's assessment was intended to include both the resident population and the resources needed to care for them. However, when asked to identify where the assessment addressed staffing levels, skills, competencies, and training programs, the Administrator was unable to provide specific sections that contained this information. The Administrator later indicated that these questions were addressed in the Acuity and Cognitive Sufficiency Analysis Summary sections, but a review of these sections showed they were also incomplete.
Failure to Provide Residents with Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had reasonable and ready access to their personal funds held by the facility. During a resident council meeting, four residents expressed concerns about difficulties in obtaining money during evenings and weekends. One resident mentioned uncertainty about accessing funds after office hours, while another noted that outings had to be canceled due to the unavailability of funds. Interviews with staff, including a receptionist and several nurses, revealed that the facility kept an emergency fund of $50 for such situations, but this amount was limited and had to be rationed among residents. Staff members were generally unaware of how to handle requests for funds outside of regular office hours, leading to delays in residents accessing their money. The receptionist confirmed that there had been instances where outings were canceled due to insufficient funds, although the exact reasons were unclear. Licensed Practical Nurses (LPNs) and a Registered Nurse (RN) interviewed admitted they did not know how residents could access their funds during evenings or weekends and would typically advise residents to wait until the next business day. The RN mentioned that they were not allowed to handle resident funds and would need to consult a nurse on call for guidance, but ultimately, residents would have to wait until office staff were available. This lack of access to personal funds affected the residents' ability to participate in activities and manage their financial affairs as needed.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure the living areas for residents were clean, safe, and sanitary. During a tour, it was discovered that the P-Tac vents in several rooms were heavily soiled with a thick layer of debris, and the maintenance helper confirmed that these should be cleaned or replaced monthly. However, documentation of the last cleaning was not provided, and the records indicated the last cleaning was done two months prior. Additionally, the facility had poor quality furniture, with nightstands in several rooms peeling and exposing particle boards, making them difficult to clean properly. Despite the administrator's acknowledgment of the issue, the same nightstands were found in use in resident rooms during a follow-up observation. The facility also had issues with damaged ceilings, with one resident reporting a leaking ceiling for over two months, resulting in dark brown stains and a strong odor of mildew. The maintenance staff confirmed the leak but provided inconsistent information about when it started. Another room had a severely damaged ceiling with plaster falling off and a strong mildew odor, and the resident had to be moved to another room. Additionally, a resident's wheelchair was found with a large amount of clear tape holding a cup holder to the armrest, which was not properly addressed until two days later. These deficiencies indicate a failure to maintain a safe, clean, and comfortable environment for the residents.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications used for refusal of care. This deficiency was identified for two residents. Resident #5 had an order for Abilify, an antipsychotic medication, prescribed for refusal of care, combative behavior, and aggression. The Director of Nursing (DON) acknowledged that medications should not be given for refusal of care. Similarly, Resident #91 had an order for Abilify to be administered at bedtime for mood and refusal of care. The resident was observed sleeping at various times throughout the day, and the Medication Administration Record (MAR) indicated that the resident received Abilify daily in February and March. The MAR also showed inconsistent documentation regarding monitoring for side effects, with some days marked as 'Not Applicable' despite the medication being administered. The DON was informed about the inappropriate use of Abilify for refusal of care and the discrepancies in monitoring for side effects. The observations and records indicated that the facility did not adhere to proper protocols for administering psychotropic medications, leading to unnecessary medication use for the residents involved.
Failure to Update PASRR for Residents with Mental Disorders
Penalty
Summary
The facility failed to update the Pre Admission Screening and Resident Review (PASRR) for residents diagnosed with serious mental disorders upon admission. This deficiency was identified for nine out of ten residents reviewed during the long-term care survey process. Specifically, residents with diagnoses such as major depressive disorder, bipolar disorder, and psychosis were not accurately reflected in their PASRR documentation. For instance, Resident #82, #38, and #6 were admitted with major depressive disorder, but their PASRRs did not mark this diagnosis. Similarly, Resident #32 and #29 had bipolar disorder, but their PASRRs failed to identify this condition. Additionally, Resident #37 and #102 had diagnoses of psychosis and bipolar disorder, respectively, which were not updated in their PASRRs. Resident #77 also had an admitting diagnosis of bipolar disorder that was not reflected in the PASRR documentation. The deficiencies were confirmed through record reviews and staff interviews. The Director of Nursing (DON) and Social Workers acknowledged the missing diagnoses in the PASRRs and confirmed that new PASRRs had not been completed to reflect the residents' current mental health conditions. The failure to update the PASRRs meant that the need for specialized services was not assessed, potentially impacting the care provided to these residents. The facility census at the time of the survey was 106 residents.
Failure to Provide RSV Immunization and Follow Insulin Orders
Penalty
Summary
The facility failed to provide information and offer the Respiratory Syncytial Virus (RSV) immunization to residents as recommended by the CDC. A review of facility documents revealed that none of the 106 residents had been provided educational information about the risks and benefits of receiving the RSV vaccination. The Infection Preventionist confirmed that the facility did not offer the RSV vaccine, despite CDC recommendations for adults aged 60 and older to receive the vaccine to protect against severe RSV. The CDC had made the RSV vaccine available in early August 2023, and simultaneous administration with other vaccines was considered best practice. Additionally, the facility failed to follow a physician's order regarding insulin administration for a resident. The resident had an order for insulin on a sliding scale, but a review of the Medication Administration Records (MARs) for October, November, and December 2023 revealed multiple instances where nursing staff failed to obtain blood glucose levels and left the MARs blank. The Director of Nursing acknowledged that the documentation on these dates did not meet professional standards of practice, as nursing staff should have taken the resident's blood glucose level, documented it, and assessed if Novolog needed to be administered.
Failure to Label Multi-Use Insulin Vials
Penalty
Summary
The facility failed to ensure all vials of multi-use insulin were labeled with the initial date they were opened. This deficiency was observed in three out of three vials found in the medication cart, affecting residents #32, #71, and #72. On 03/13/24 at 9:06 AM, RN #28 verified that the insulin vials for these residents did not have a date indicating when they were first accessed. Specifically, a multi-use vial of Lispro for Resident #32, a multi-use vial of Lantus for Resident #71, and a multi-use vial of Levemir for Resident #72 were found without the required date. According to the CDC, a multi-use vial should not be used longer than 30 days once punctured. The Director of Nursing (DON) was informed of these issues on 03/13/24 at 11:30 AM.
Improper Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety. During a kitchen tour, it was observed that a box of breaded fish filets was not sealed properly, exposing the filets to the elements in the walk-in freezer. Additionally, a trash can was situated in front of the beverage dispensers, causing staff to lean over the trash can to fill beverage pitchers. A large section of a floor tile was missing beside the ice machine, and the floor of the walk-in freezer had debris and food particles under the shelving unit. The Dietary Manager verified these issues during an observation and interview.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. The P-Tac vents in rooms 301, 302, 303, 304, and 305 were found to be heavily soiled with a thick layer of debris, and the maintenance helper confirmed that these should be cleaned or replaced monthly. However, documentation showed the last cleaning was done two months prior. Additionally, the facility had poor quality furniture, with nightstands in several rooms peeling and exposing particle boards, making them difficult to clean properly. Despite the administrator's acknowledgment of the issue, the same damaged furniture was found in use in multiple rooms during the survey. The facility also had issues with damaged ceilings. In one room, a resident reported a leaking ceiling that had been an ongoing problem for two months, with dark brown stains and a strong odor of mildew. Another room had a leaking ceiling with plaster falling off, exposing discolored and damaged sheetrock. The maintenance staff and district maintenance manager were aware of the issue, but there was no evidence of timely action taken to address the leaks. The affected residents had to be moved to other rooms due to the unsafe conditions. Furthermore, a resident's wheelchair was found with a large amount of clear tape holding a cup holder to the armrest. Despite a licensed practical nurse's promise to put in a work order to fix it, the tape was still present the following day. It was only on the third day that the cup holder was properly attached. These deficiencies indicate a failure by the facility's Quality Assessment and Assurance committee to make good faith attempts to correct known quality deficiencies, compromising the safety and comfort of the residents.
Infection Control Deficiencies in Bedpan Storage, Laundry Services, and Ice Machine Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies. Observations revealed that used bedpans for three residents were stored together without covers in a bathtub, which was confirmed by a nurse aide who stated they should be stored in bags with names on them. Additionally, the laundry services were found to be inadequate, with no sealed separation between the soiled and clean laundry areas, and no negative air flow to prevent contamination. The laundry room had bags of soiled laundry on the floor, lint buildup on washer filters, and non-functional vents with dust and dirt accumulation. The Laundry Supervisor confirmed these issues and acknowledged that the facility was aware of them but had not yet corrected them. Another deficiency was observed when a resident was seen retrieving ice from a community ice machine, despite being told multiple times not to do so. The Director of Nursing was informed of this incident and expressed uncertainty about how to prevent it from happening again. These practices had the potential to affect all residents in the facility, compromising the overall infection control and prevention measures.
Failure to Honor Resident's Dietary Choices
Penalty
Summary
The facility failed to honor a resident's dietary choices, specifically regarding lactose intolerance. On 03/11/24, the resident reported receiving a grilled ham and cheese sandwich despite being lactose intolerant and having cheese listed as a dislike on her meal ticket. The resident's care plan indicated she should be provided with Lactaid milk and monitored for nutritional intake due to multiple health conditions, including Type 2 Diabetes Mellitus, adult failure to thrive, hypothyroidism, major depressive disorder, Chronic Kidney Disease Stage 3B, and Congestive Heart Failure. The meal ticket did not include cheese sandwiches under dislikes, leading to the resident receiving inappropriate food. The Director of Nursing was informed and acknowledged the oversight.
Failure to Notify Resident's Representative of Change in Care
Penalty
Summary
The facility failed to notify the resident's representative in a timely manner when there was a change in care. Specifically, an antibiotic, Amoxicillin, was ordered for a resident on 03/08/24 to treat a dental abscess, but the resident's Medical Power of Attorney (MPOA) was not informed of this new medication order. The resident had swelling and bruising on the left jaw area, which was noted in the medical records, but there was no evidence that the MPOA was notified about the dental abscess or the antibiotic treatment. During a telephone interview, the resident's MPOA expressed concern about the bruising on the resident's cheek and neck, which she noticed during a visit. The MPOA was unaware of the tooth infection and the antibiotic treatment. The Director of Nursing confirmed that there was no evidence that the MPOA had been notified of the new order for Amoxicillin to treat the dental abscess.
Failure to Ensure Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure a resident's right to privacy and confidentiality. During a visit, it was observed that a resident had three signs posted in her room containing personal care information, such as 'I do not get up alone,' 'I get help for the bathroom,' and 'No straws.' The resident lacked decision-making capacity and had a family member serving as her Medical Power of Attorney (MPOA), who confirmed that the signs were not requested by the family. The Social Worker confirmed that the signs were visible to others and included clinical and personal information, and that the need for the signage was not care planned.
Failure to Timely Report Resident Fall with Serious Injury
Penalty
Summary
The facility failed to report a resident fall resulting in serious bodily injury to the appropriate state agencies in a timely manner. This deficiency was identified during a review of records and staff interviews. Specifically, a resident fell in her bathroom and was subsequently diagnosed with multiple injuries, including a nasal bone fracture. Despite the facility's knowledge of the serious injury, the incident was not reported within the required two-hour timeframe and was instead reported four days later. The delay in reporting was attributed to the absence of both social workers over the Thanksgiving holiday.
Failure to Notify State Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide the Notice of Transfer to the State Ombudsman for a resident who was transferred to another long-term care facility. This deficiency was identified during a medical record review on 03/13/24, which revealed that the notice was not sent when the resident was transferred on 12/12/23. The Licensed Social Worker confirmed in an interview that the Notice of Transfer was not sent to the State Ombudsman for the resident in question.
Failure to Update PASARR for Resident with Schizophrenia
Penalty
Summary
The facility failed to update the Pre Admission Screening and Resident Review (PASARR) for a resident diagnosed with a serious mental disorder after admission. Specifically, a record review for a resident revealed that the resident was admitted to the facility and later diagnosed with schizophrenia, but the PASARR was not updated to reflect this diagnosis. The PASARR only indicated a seizure disorder as a current diagnosis. The Director of Nursing was notified and acknowledged the missing diagnosis from the resident's PASARR.
Failure to Develop Discharge Planning Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for discharge planning for Resident #105. During a medical record review on 03/13/24, it was revealed that Resident #105 was discharged on an unspecified date without a developed care plan for discharge planning. This deficiency was confirmed in an interview with the Licensed Social Worker (LSW) on 03/13/24 at 9:20 AM, who verified that the care plan had not been developed for discharge planning for Resident #105. The facility census at the time was 106 residents.
Failure to Revise Care Plan After Urinary Catheter Removal
Penalty
Summary
The facility failed to revise a person-centered comprehensive care plan for a resident following the removal of an indwelling urinary catheter. Specifically, the care plan for Resident #84 was not updated to reflect the removal of the urinary catheter on 02/05/24. This deficiency was identified during a medical record review on 03/13/24 and confirmed through an interview with the Director of Nursing (DON) on the same day. The facility's census at the time was 106 residents, and this issue was noted for one of the four resident care plans reviewed for urinary catheter care during the Long-Term Care Survey Process (LTCSP).
Failure to Provide Preferred Bathing Method and Hair Washing
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #38, who had been at the facility for a couple of weeks, reported only receiving bed baths despite a preference for showers and a desire to have their hair washed. The Director of Nursing (DON) confirmed that the resident was scheduled to receive baths on Wednesdays and Saturdays, but records indicated that showers were documented on several dates. However, the resident confirmed that they had only received bed baths during this period. Licensed Practical Nurse (LPN) #140 acknowledged that there were issues with documentation from the aides, and upon review, it was found that Nurse Aides #11 and #160 had incorrectly documented showers instead of bed baths. The DON was notified and acknowledged the discrepancy, confirming that Resident #38 had not had their hair washed as per their preference. This failure to provide the preferred method of bathing and hair washing constitutes a deficiency in the care provided to the resident.
Medication Found on Floor in Resident's Room
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards, as evidenced by a prescribed medication found on the floor in a resident's room. During an in-room visit, an unidentified white, round, scored pill was discovered on the floor in front of the resident's bed. The pill was later identified by an LPN as Amiodarone, a medication prescribed for atrial fibrillation (AFib). The presence of the medication on the floor indicates that the resident may not have ingested the medication as intended, posing a potential health risk given the serious nature of the medication's use and its boxed warnings from the FDA. The Director of Nursing (DON) confirmed awareness of the incident and stated that it is a professional standard of practice for nurses to ensure all medications have been swallowed before documenting successful administration on the medication administration record (MAR). The failure to adhere to this standard practice led to the medication being found on the floor, highlighting a lapse in the supervision and administration of medication within the facility. The facility census at the time was 106 residents.
Failure to Ensure Residents Were Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications. For Resident #5, an order for Abilify was written to address refusal of care, combative behavior, and aggression. The Director of Nursing (DON) acknowledged that medications should not be given for refusal of care. Additionally, Resident #5 had a PRN order for Xanax that extended beyond the 14-day limit without a provided rationale, which the DON could not justify during the survey. No further information was available at the close of the survey regarding this issue. For Resident #91, an order for Abilify was also written to address refusal of care. The resident was observed sleeping at various times over several days, and the Medication Administration Record (MAR) indicated that Abilify was administered daily in February and March. Despite this, the MAR inconsistently documented the resident's freedom from side effects, with some days marked as 'Not Applicable.' The DON acknowledged the inappropriate order for Abilify, the resident's frequent sleeping, and the inconsistent documentation of side effects monitoring.
Failure to Provide Assistive Devices for Eating
Penalty
Summary
The facility failed to provide appropriate assistive devices to a resident who needed them to maintain or improve their ability to eat independently. During a noon meal observation, Resident #37 was found having issues drinking her milk. The resident's tray card indicated the use of a spout cup, but Nurse Aide #67 stated that the resident did not like the spout cup and therefore it was not provided. A review of the resident's care plan revealed that the resident was dependent on assistance for activities of daily living (ADLs) due to paralysis affecting the left extremities and required the use of a proval cup (blue handles) for all liquids. The Corporate Nurse confirmed that the resident needed the blue-handled cup as per the care plan and diet order for dysphagia advanced texture.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For Resident #38, the facility did not accurately document the type of ADL care provided. Despite the resident's preference for showers and the facility's schedule indicating showers on specific days, the resident only received bed baths. Documentation inaccurately recorded that the resident received showers on multiple dates, which was confirmed to be incorrect by both the resident and an LPN. The LPN admitted to not being aware of the documentation requirements and acknowledged ongoing issues with aide documentation accuracy. For Resident #91, the facility failed to accurately record side effects of psychotropic medications. The resident was prescribed Abilify for mood target behavior and was observed sleeping at various times, suggesting potential side effects. However, the MAR consistently indicated that the resident was free from side effects, except for two days marked as not applicable. The DON acknowledged the discrepancies in documentation and the need for accurate monitoring of side effects.
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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