Pine View Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Harrisville, West Virginia.
- Location
- 400 Mckinley Avenue, Harrisville, West Virginia 26362
- CMS Provider Number
- 515184
- Inspections on file
- 18
- Latest survey
- October 30, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pine View Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident's privacy was compromised during visitation due to another resident's disruptive behavior, including opening doors, cursing, and attempting to enter the room. Despite staff attempts to redirect the disruptive resident, the behavior persisted, affecting the resident's family visits. The facility administrator acknowledged the issue, confirming the lack of privacy provided.
The facility failed to promptly address grievances and keep residents informed of the progress toward resolution. One resident experienced ongoing disruptive behavior from another resident, with no grievance form completed or room change offered. Another resident filed a grievance against a staff member but received no response or written resolution. The facility did not adhere to its grievance policy, resulting in unresolved grievances and lack of communication.
The facility failed to store and label food according to professional standards, as observed in the kitchen's pantry and freezer. Unlabeled vanilla ice cream cups and cooked frozen sausage with inconsistent dates were found, confirmed by the Dietary Manager, indicating lapses in food storage practices.
A facility failed to issue a timely Notification of Medicare Non-Coverage (NOMNC) for a resident discharged home after Medicare Part A services ended. The resident, admitted with an altered mental state and weakness, met therapeutic goals for discharge. However, the NOMNC was not provided at least two days before service termination, as confirmed by the Business Office Manager.
A facility failed to provide a written Notice of Transfer/Discharge to a resident and the LTC Ombudsman during a hospitalization. A review showed no documentation of the notice, which should have included the reason for transfer, effective date, new location, and appeal rights. The Administrator confirmed the lack of evidence for these notifications.
The facility failed to provide written Bed Hold notices to two residents or their representatives during hospital transfers, as required. One resident was transferred to the hospital without evidence of a Bed Hold notice, confirmed by the Administrator. Another resident was discharged without documentation of a Bed Hold notice or contact with the resident or representative, confirmed by the DON.
The facility failed to update the PASARR for two residents with new mental health diagnoses. One resident had a Major Depression diagnosis, and another had a Bipolar Disorder diagnosis, but their PASARRs did not reflect these changes. The social worker confirmed the absence of updated PASARRs.
A facility failed to implement a person-centered care plan for a resident by not specifying her preferred bedtime. The resident expressed a desire to choose her bedtime, but the care plan included multiple options without indicating her actual preference. The Administrator confirmed the care plan was not person-centered.
A facility failed to contact a physician for a reassessment of a resident's capacity after a BIMS evaluation showed severe impairment. The resident, who had been hospitalized for a UTI and returned on hospice care, showed a significant decline in mental status. Despite this, the facility did not follow up with the physician, as confirmed by staff interviews.
The facility failed to follow physician orders for oxygen administration and monitoring for two residents. One resident was observed with an oxygen concentrator set below the prescribed level, and monitoring records were inconsistent and incomplete. An LPN confirmed the incorrect setting and adjusted it, but noted she was unfamiliar with the patients. Another resident also had incorrect oxygen settings and inconsistent monitoring, which was confirmed by another LPN and the administrator.
A facility failed to provide trauma-informed care for a resident with PTSD, stemming from a past traumatic event. The care plan inappropriately relied on the resident, who had severe cognitive impairment, to identify his own trauma triggers. The social worker was unaware of the resident's PTSD specifics and did not engage with the resident's family to gather necessary information, leading to inadequate care planning.
The facility did not complete and document annual performance reviews for all nurse aides, specifically affecting two employees. This oversight was confirmed by the Scheduling/payroll Manager and had the potential to impact the care of residents, given the facility's census.
The facility failed to ensure monthly drug regimen reviews were conducted by a licensed pharmacist for two residents. There was no evidence of completed reviews for specific months in the electronic medical records. The Administrator confirmed the lack of documentation for these reviews.
Privacy Violation During Resident Visitation
Penalty
Summary
The facility failed to ensure privacy for a resident during visitation, as evidenced by repeated incidents involving another resident's disruptive behavior. The resident's Medical Power of Attorney reported that visitors, including herself, experienced issues with another resident who frequently opened the door, cursed at visitors, and attempted to enter the room. Despite these occurrences, no grievance form was filled out to document the issues. Progress notes revealed multiple instances where the disruptive resident opened the door, laughed, and left, or was found inside the room, refusing to comply with requests to leave or be redirected by staff. The disruptive resident exhibited verbally aggressive behavior towards staff and visitors, particularly when the resident's family members were present. This behavior included cursing, yelling, and physical aggression, such as attempting to kick and hit staff. The facility's staff attempted to redirect the disruptive resident, but he consistently refused to comply, necessitating intervention by multiple staff members to remove him from the area. The facility administrator acknowledged awareness of the complaint and confirmed that the resident and her visitors were not provided privacy during visitation.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to promptly address grievances and keep residents informed of the progress toward resolution, as evidenced by the experiences of two residents. For one resident, multiple complaints were made regarding another resident's disruptive behavior, including entering the room uninvited, cursing, and being verbally aggressive. Despite these ongoing issues, no grievance form was completed, and the resident's family was not offered a room change until much later. The facility's policy required immediate action to prevent further violations and timely notification of resolution, which was not adhered to in this case. Another resident filed a verbal grievance against a staff member, but the facility did not provide any response regarding the status of the investigation. The resident's Medical Power of Attorney also expressed concern about the lack of communication from the facility. Although the facility conducted an investigation and concluded that the grievance could neither be substantiated nor refuted, they failed to notify the resident or provide a written resolution as required by their policy. The facility's grievance policy outlined specific steps for handling grievances, including documenting the grievance, taking immediate action, and notifying the person filing the grievance in a timely manner. However, in both cases, the facility did not follow these procedures, resulting in a failure to resolve grievances promptly and keep residents informed, as required by regulations.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service storage, as evidenced by observations in the kitchen's pantry and freezer. In the pantry area, small cups of what appeared to be vanilla ice cream were found unlabeled and without any dates. Additionally, in the freezer, cooked frozen sausage was discovered with a date labeled as 10/28/24, which was inconsistent with the use-by date of 04/22/24. These findings were confirmed by the Dietary Manager during the kitchen investigation, indicating a lapse in proper food labeling and storage practices.
Failure to Issue Timely NOMNC for Resident Discharge
Penalty
Summary
The facility failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely manner for a resident who was reviewed for beneficiary protection notification. The resident, who was discharged to home after the last covered day of Medicare Part A services, did not receive the NOMNC at least two calendar days before the end of the covered services, as required by the Form Instructions for the NOMNC CMS-10123. This oversight was confirmed during an interview with the Business Office Manager, who acknowledged that the NOMNC was not issued prior to the resident's discharge. The resident in question had been admitted to the facility with an altered mental state and overall weakness, with a care plan goal of returning to home/community living. The resident met the therapeutic goals established for discharge, as confirmed by the discharge summaries from physical, occupational, and speech therapy. Despite the resident's desire and readiness to return home, the facility's failure to provide the NOMNC in a timely manner meant the resident was not informed of their rights before the termination of Medicare Part A services.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to a resident and the long-term care Ombudsman during a hospitalization event. A medical record review revealed that a resident was transferred to the hospital, but there was no documentation indicating that the resident or their representative received a written notice detailing the reason for the transfer, the effective date, the new location, and the resident's appeal rights. Additionally, there was no evidence in the electronic medical record that the long-term care Ombudsman was notified of the transfer. During an interview, the Administrator confirmed that the facility could not produce evidence of the required notifications.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to provide written Bed Hold notices to residents or their representatives during hospital transfers, as required. This deficiency was identified during the annual Long-Term Care Survey Process for two residents. Resident #27 was transferred to the hospital on May 17, 2024, but there was no evidence in the electronic medical record that a Bed Hold notice was provided. The facility's Administrator confirmed the absence of such documentation. Similarly, Resident #16 was discharged to a local hospital on October 20, 2024, without documentation of a Bed Hold notice being issued or any contact with the resident or their representative regarding the bed hold policy. The Director of Nursing confirmed the lack of documentation for Resident #16's transfer.
Failure to Update PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASARR) for residents with newly evident or possible serious mental disorders. This deficiency was identified during the Long-Term Care Survey Process for two residents. Resident #6 was admitted with a diagnosis of Major Depression, effective from November 1, 2023, but the only PASARR on file was dated November 2, 2022, which did not reflect this diagnosis. The social worker confirmed that no updated PASARR was available to address the Major Depression diagnosis. Similarly, Resident #28 was admitted with a diagnosis of Bipolar Disorder, effective from September 26, 2024. The initial PASARR dated March 26, 2024, and a subsequent PASARR dated July 16, 2024, did not capture the Bipolar Disorder diagnosis. The social worker also confirmed the absence of a new PASARR reflecting this diagnosis. These findings indicate a failure to update the PASARRs to reflect significant changes in the residents' mental health conditions.
Failure to Implement Person-Centered Care Plan for Resident's Bedtime Preference
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #145, during the Long-Term Care Survey process. The deficiency was identified when the facility did not address the resident's preferred bedtime preference in her care plan. A record review revealed that the resident, who was admitted to the facility, expressed a preference to go to bed whenever she wanted, as noted in her Recreation Comprehensive Assessment dated 10/18/24. However, the comprehensive care plan created on 10/21/24 included an intervention that was not specific to the resident's preference, as it listed multiple options for bedtime without indicating the resident's actual choice. During an interview, the Administrator confirmed that the care plan was not person-centered, and it was unclear what the resident's bedtime preference was based on the intervention listed.
Failure to Reassess Resident's Capacity After Severe Impairment Noted
Penalty
Summary
The facility failed to contact the physician and request a reassessment of a resident's capacity after a Brief Interview for Mental Status (BIMS) evaluation revealed severe impairment. Resident #18, who had a history of severe impairment, was unable to recall when she entered the facility or how long she had been there during an interview. Despite this, the facility did not follow up with the physician for a reassessment of her capacity, even though a previous document from the resident's physician dated two months earlier stated that the resident had capacity. Further record review showed that Resident #18 had been admitted to the hospital for an acute urinary tract infection and was later discharged back to the facility on hospice care. A subsequent BIMS evaluation conducted by the social worker indicated a significant decline in the resident's mental status, with a score dropping from 12.0 to 5.0. Despite these findings, the facility did not take action to reassess the resident's capacity, as confirmed by interviews with the social worker and the facility administrator.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician orders regarding oxygen administration and monitoring for two residents. Resident #5 was observed on oxygen therapy with the concentrator set at 2 liters per minute, contrary to the physician's order of 3 liters per minute via nasal cannula as needed. The monitoring records for Resident #5's oxygen saturation were inconsistent and incomplete, with no records available for specific dates during the survey period. LPN #29 confirmed the incorrect oxygen setting and adjusted it accordingly, but noted that she was not familiar with the patients as she was covering the hallway temporarily. Similarly, Resident #11 was observed receiving oxygen therapy with the concentrator set below the prescribed 3 liters per minute. The monitoring records for Resident #11 also showed inconsistencies, with no records available for several days during the survey. LPN #49 confirmed the incorrect setting and adjusted it to the correct dosage. The administrator acknowledged the lack of consistent monitoring for both residents, confirming that the facility did not follow the prescribed orders for oxygen therapy and monitoring.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The deficiency was identified during a review of the care provided to a resident who had a significant traumatic experience in his past, specifically related to a disaster at a power plant construction site. Despite the resident's severe cognitive impairment, the care plan inappropriately relied on the resident to identify his own trauma triggers, which was unrealistic given his condition. The care plan did not include input from the resident's family, who could have provided valuable insights into the resident's trauma history and potential triggers. The social worker at the facility admitted to not knowing the specifics of the resident's PTSD diagnosis or any potential triggers that could re-traumatize him. This lack of knowledge and failure to engage with the resident's family to gather necessary information resulted in inadequate care planning. The facility's oversight in not collaborating with the resident's family to identify and address trauma triggers contributed to the deficiency in providing culturally competent and trauma-informed care.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to conduct and document a completed performance review for every nurse aide at least once every 12 months. This deficiency was identified through personnel file record reviews and staff interviews, specifically affecting employees #49 and #5. During an interview, the Scheduling/payroll Manager confirmed that the yearly performance reviews were not on file for these employees. This oversight had the potential to affect more than a limited number of residents, given the facility's census of 47.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review, including a review of the medical chart, for two of the five residents reviewed under the unnecessary medication's pathway. For Resident #27, there was no evidence in the electronic medical record that a medication regimen review was completed for the months of November 2023 and December 2023. Similarly, for Resident #28, there was no evidence of a completed medication regimen review for August 2024. During an interview, the Administrator confirmed the facility's inability to provide evidence that these reviews were conducted by the consulting pharmacist or reviewed by the attending physician.
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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