Pocahontas Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marlinton, West Virginia.
- Location
- 5 Everett Tibbs Road, Marlinton, West Virginia 24954
- CMS Provider Number
- 515183
- Inspections on file
- 20
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 21 (2 serious)
Citation history
Health deficiencies cited at Pocahontas Center during CMS and state inspections, most recent first.
A resident attempted to elope from the facility, but staff failed to document the incident and did not notify the resident’s physician or responsible party. An LPN acknowledged the incident and reported it verbally to the DON, and the DON later confirmed the attempted elopement and the absence of any progress notes or notification records related to the event. This omission was identified during a complaint investigation, based on review of clinical records and interviews with staff.
A resident with dysphagia and recent pneumonia was served regular consistency milk and coffee instead of the ordered nectar thickened liquids, despite clear physician orders and care plan instructions. The resident drank the thin liquids and experienced coughing, and the inconsistency was confirmed by both a surveyor and the interim DON during a meal observation.
The facility did not consistently provide enough nursing staff to meet the required minimum nursing hours per patient day (NHPPD) on multiple days, as confirmed by staff interviews and record reviews. This deficiency was identified over a review period involving 59 residents.
The facility did not include the required census information on four daily nurse staffing postings across multiple shifts, as confirmed by administrative staff. This deficiency was identified during a review of staffing records.
A facility did not complete an accurate and thorough investigation for an abuse allegation, with errors found in the resident's capacity status, BIMS assessment dates, and the use of an incorrect name in the incident report. These documentation discrepancies were confirmed by a corporate RN.
Annual performance reviews for nurse aides were not completed as required, with three out of five aides missing their reviews by the due dates, as confirmed by facility leadership.
A resident with a history of aggressive and inappropriate behaviors was not adequately managed, leading to multiple incidents of abuse towards other residents and staff. The facility failed to report these incidents, notify the physician and responsible parties, and implement effective interventions, resulting in an Immediate Jeopardy situation.
The facility did not maintain the dryer in a safe manner, as observed in the laundry room where lint traps were full and overflowing onto the floor. The Environmental Services Operations Manual requires lint screens to be cleaned after every load or every hour to prevent fire hazards. An employee acknowledged the fire risk posed by the overflowing lint traps.
The facility failed to provide the required RN coverage for eight consecutive hours daily. On one occasion, there was no RN on staff for the entire day, and on another, only 7.83 hours of coverage were provided. This deficiency was confirmed by the facility's scheduler and has the potential to affect all 67 residents.
The facility failed to complete a staff evaluation for a CNA. The evaluation was conducted by the DON, but a post-it note indicated that the CNA missed going over the review with the DON. The Scheduler confirmed that the evaluation was incomplete and should have been completed when the CNA returned.
The facility failed to ensure safe and sanitary food service practices, affecting all residents receiving nutrition from the kitchen. Staff did not wash hands or wear gloves before handling serving spoons, and kitchen staff did not wear beard restraints as required. These actions were contrary to the facility's policies on food preparation and staff attire.
The facility did not identify the necessary CNA and nursing competencies to meet resident care needs. Although the facility assessment marked nursing competencies as sufficient, the PIC and an assisting Administrator could not specify any required competencies for nursing staff. This deficiency was found during a random review of CNA/nursing competencies, potentially affecting many residents.
A facility failed to implement its Abuse Prohibition policy, leading to multiple incidents involving a male resident with a history of sexual behaviors and aggression. Despite numerous documented instances of inappropriate behavior, the facility did not report these to the physician or POA, nor did it conduct thorough investigations or follow-up assessments. Interviews revealed a lack of awareness and action from staff, and the facility's corporate Clinical Lead Nurse acknowledged the failure to implement the policy and report incidents appropriately.
The facility failed to report and investigate incidents of abuse involving a resident with a history of inappropriate behavior. Despite multiple documented incidents of verbal, physical, and sexual aggression, the facility did not notify the physician or the resident's POA, nor did they conduct necessary investigations. Staff interviews revealed a lack of awareness and reporting of abuse, and the facility's policy on abuse prohibition was not implemented, leaving residents unprotected.
The facility failed to investigate abuse allegations as per their policy, involving a male resident with a history of inappropriate behaviors. Despite documented incidents of verbal, physical, and sexual aggression, the facility did not conduct thorough investigations, notify the physician or POA, or protect residents from further harm. Staff interviews confirmed awareness of the behaviors, yet the facility's abuse prohibition policy was not implemented.
The facility was found to have expired medical supplies, including BD Blood Transfer Devices and urinary catheters, in the medication and supply storage room. This deficiency was confirmed by an RN and has the potential to affect many residents.
The facility did not ensure that residents received a substantial evening snack, as required by their policies. Two residents reported not being offered snacks for several weeks, while others had to request them from the nurse's station. The facility's policies state that snacks should be delivered to the nursing station and offered to every resident, but this was not consistently done.
The facility failed to prevent infections by storing clean resident clothing in a chemical closet on the dirty side of the laundry room, where it was in direct contact with a cleaning solution used for mops. An employee stated that unlabeled clothing is kept in this closet until claimed, acknowledging the contamination risk.
A facility failed to provide a dignified dining experience when an RN assisted a resident with eating while standing over the bed, despite an available chair. The RN was concerned about a laptop on the over-the-bed table and acknowledged the inappropriate action.
A facility failed to document the provision of information regarding advanced directives for a resident. A record review revealed the absence of an Advanced Directive, and a staff member confirmed that no documentation was present to show that the resident or their representative had been informed about implementing an Advanced Directive. The resident's representative wanted the resident to remain a DNR, and a care plan meeting was scheduled to discuss this further.
The facility failed to maintain a safe and homelike environment for residents. In one room, soiled privacy curtains with brown and red substances were observed and left unchanged. In another unit, a bedside nightstand had a torn laminate surface, exposing rough edges and particle board, posing a risk for skin tears. These issues were confirmed by a RN and the Corporate Clinical Lead.
The facility did not provide a means for residents to report grievances anonymously, as revealed during a resident council meeting. The admissions director acknowledged the lack of an anonymous submission system, despite the facility's policy requiring confidentiality for grievances, including those submitted anonymously.
A facility failed to notify the Ombudsman of a resident's hospital transfer after a change in condition with abnormal vital signs. The responsibility for notification was assigned to a Social Worker who was on medical leave, and the Clinical Reimbursement Coordinator confirmed that the notification was not completed.
The facility failed to notify resident representatives of the bed hold policy during transfers to the hospital for two residents. One resident was transferred due to abnormal vital signs, and another due to vomiting blood. In both cases, the required bed hold notifications were not completed, as confirmed by facility staff.
The facility failed to coordinate with the State-designated authority to ensure residents with mental disorders received appropriate care by not accurately completing or updating their PASSR forms. This deficiency was identified for three residents, whose PASSR forms were missing critical diagnoses such as Schizoaffective Disorder, PTSD, and Bipolar Disorder, as confirmed by facility staff.
A facility failed to monitor potential triggers for a resident with PTSD, despite the resident's multiple diagnoses and prescribed psychotropic medications. The care plan lacked specific interventions for PTSD, and the facility did not assess or document potential triggers, contrary to its policies. The Corporate Clinical Lead Nurse acknowledged these deficiencies.
The facility failed to update care plans for two residents when their care needs changed. One resident's care plan was not revised after their insulin was discontinued, and another resident's care plan did not reflect their current hospice status and inability to participate in activities. These issues were confirmed by the Corporate Clinical Lead.
A facility failed to report elevated blood glucose levels for a resident as per physician orders. The resident's blood glucose levels exceeded the specified threshold on multiple occasions, yet these were not communicated to the physician. This lapse was confirmed by the Corporate Clinical Lead.
A resident in a LTC facility did not receive timely incontinence care despite using the call bell to request assistance. A staff member turned off the call bell and delayed care until after meal trays were cleared, citing a non-existent policy about linen carts. The facility's Corporate Clinical Lead Nurse confirmed there was no such policy, acknowledging the resident should have received prompt care.
A facility failed to monitor potential triggers for a resident with PTSD, who was also diagnosed with dementia, schizoaffective disorder, bipolar disorder, and major depressive disorder. Despite being on psychotropic medications, there was no behavior monitoring documented, and the care plan lacked interventions for PTSD. The facility's policy requires identifying and mitigating triggers, but this was not done, as acknowledged by the Corporate Clinical Lead Nurse.
The facility failed to provide necessary social services for discharge planning and healthcare decision-making for two residents. One resident needed assistance with housing to be discharged, but the absence of a social worker left her without support. Another resident experienced a change in capacity, and a decision maker was not promptly appointed, leaving him without a designated person for medical decisions. The admissions department, lacking licensed social workers, could not adequately fill the gap, leading to these deficiencies.
A facility failed to monitor behaviors for a resident receiving psychotropic medication, as identified during a survey. The resident had multiple diagnoses, including PTSD and Schizoaffective Disorder, and was prescribed Fluphenazine and Seroquel. However, there was no documentation of behavior monitoring in the medication administration record, contrary to the facility's policy. The Corporate Clinical Lead Nurse acknowledged the lack of documentation.
A resident with multiple mental health diagnoses, including PTSD, had an incomplete medical record. The facility's Social Worker failed to document the PTSD diagnosis in the Social Determinants of Health assessment, and the care plan did not address PTSD. The Corporate Clinical Lead Nurse acknowledged the error.
The facility failed to post daily nurse staffing information in a prominent location, making it inaccessible to residents and visitors. Additionally, the staffing forms contained inaccuracies, such as incorrect CNA and RN numbers and hours, missing census data, and inclusion of administrative hours as direct care. The facility Scheduler confirmed these discrepancies.
Failure to Notify Physician and Responsible Party After Attempted Elopement
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and responsible party of a significant change in condition following an attempted elopement. During a complaint investigation involving a resident identified as #48, surveyors reviewed progress notes, the care plan, and the incident report log and found no documentation of the attempted elopement, no record of physician notification, and no record of notification of the resident’s responsible party. An LPN interviewed on 02/02/26 at 12:19 PM acknowledged that the attempted elopement occurred and stated she reported the incident to the Director of Nursing. The Director of Nursing, interviewed later that day, confirmed that the attempted elopement occurred on 01/17/26 and acknowledged that there were no records of notifying the physician or the responsible party and no progress notes pertaining to the incident. This lack of documentation and failure to notify the physician and responsible party of the significant change in the resident’s status constituted the cited deficiency, identified in the context of a facility census of 62 residents and focused on Resident #48’s attempted elopement event.
Failure to Provide Ordered Thickened Liquids for Resident with Dysphagia
Penalty
Summary
A resident with a history of dysphagia, recent pneumonia, and COVID-19 was ordered to receive a pureed diet with nectar thickened liquids following recommendations from a speech language pathologist and physician orders. The resident's care plan and tray card specified the need for nectar consistency liquids due to aspiration precautions. Despite these orders, during a noon meal observation, the resident was served regular consistency milk and coffee by facility staff. The resident consumed the thin liquids and subsequently experienced coughing after drinking the milk. The surveyor reviewed the resident's tray card and confirmed that the liquids provided did not match the ordered nectar consistency. The interim DON was asked to verify the consistency and confirmed that the liquids were not thickened as required. This incident was identified during a random observation and was determined by the State Agency to have placed the resident at immediate risk for serious harm or death due to the failure to provide liquids in the prescribed consistency. The deficiency was based on direct observation, record review, and staff interview, confirming that the facility did not ensure the resident received liquids consistent with their individualized needs and physician orders.
Failure to Meet Minimum Nursing Staffing Requirements
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident across all shifts, as required. A review of 45 daily nurse staff postings revealed that on 18 days within the review period, the minimum nursing hours per patient day (NHPPD) of 2.25 was not met. Specific days were identified where staffing levels fell below this threshold, with some days as low as 1.48 NHPPD. The facility census during this period was 59 residents. These findings were confirmed by both the Administrator and the Regulatory Compliance Advisor during staff interviews and record reviews. No specific information about individual residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to provide accurate and complete daily staff postings, as required. Record review revealed that on four occasions, the daily staff postings did not include the facility census for all shifts on specific dates. This omission was confirmed by both the Administrator and the Regulatory Compliance Advisor during staff interviews. The facility census at the time was 59 residents. The deficiency was identified through a review of 45 daily staff postings, with four postings missing the required census information for multiple shifts.
Failure to Accurately Investigate and Document Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough and accurate investigation was completed for a Facility Reported Incident (FRI) involving an allegation of abuse. Documentation errors were identified, including discrepancies in the resident's capacity status, incorrect dates for the Brief Interview for Mental Status (BIMS), and the use of an incorrect name in the report. The resident involved had been deemed incapacitated by the facility's physician, but the FRI summary incorrectly stated the resident was capacitated. These inconsistencies were confirmed by a corporate registered nurse, who acknowledged multiple errors in the FRI documentation.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for nurse aides as required. During the survey, a review of five nurse aides' records revealed that three of the five had not received their annual performance reviews by the due dates. This finding was confirmed by both the Administrator and the Regulatory Compliance Advisor during staff interviews. No information regarding the medical history or condition of any residents was provided in relation to this deficiency.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse by another resident, identified as Resident #20, who exhibited physical, verbal, and sexually abusive behaviors towards other residents and staff. The incidents began on 04/19/23 and continued through 07/05/24, with at least 20 noted occurrences. The facility did not consistently report these behaviors as required, nor did they consistently notify the physician and responsible party. Additionally, the victims were not consistently identified, and interventions were not consistently implemented to prevent further abuse. Resident #20, a male resident with dementia and Alzheimer's disease, has a history of inappropriate sexual behaviors and aggression. Despite this, the facility failed to take adequate measures to manage his behaviors and protect other residents. Multiple incidents were documented where Resident #20 engaged in inappropriate touching, verbal aggression, and physical threats towards other residents and staff. These incidents were not properly reported or investigated, and the facility did not notify the physician or the resident's power of attorney as required by their policy. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the lack of investigations, follow-up assessments, and reporting of incidents. Interviews with staff revealed that they were aware of Resident #20's behaviors, yet no comprehensive actions were taken to address the situation. The facility's failure to adhere to its own policies and procedures resulted in an Immediate Jeopardy situation, putting residents at risk of serious harm.
Removal Plan
- Resident #20 was placed on one to one.
- The Director of Nursing (DON)/designee interviewed residents with Brief Interview for Mental Status (BIMS) of 7 or below if the resident permitted for potential sexual, verbal and physical abuse with any corrective action immediately upon discovery.
- Re-education was provided by the Director of Nursing (DON)/designee to all employees to ensure allegations of sexual, verbal, physical abuse are identified, immediate intervention put in place to prevent reoccurrence, immediately reported to the appropriate states agencies and thoroughly investigated.
- A post-test to validate understanding. Any employees not available during this time frame will be provided re-education, including post-test upon the beginning of next shift to work. New employees will be provided education, including post-test during orientation by the DON/designee.
- The Director of Nursing (DON)/designee will monitor progress notes to ensure that allegations of sexual, verbal, physical abuse have been correctly identified, reported in a timely manner and appropriate intervention put in place to prevent the reoccurrence daily across all shifts including weekends and holidays, then 3 times a week then randomly thereafter.
- Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Failure to Maintain Dryer Safety in Facility
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible by not maintaining the dryer in a safe manner. During an observation of the laundry room, it was noted that the lint traps in the facility dryers were full and had overflowed with lint onto the floor. A review of the facility's Environmental Services Operations Manual revealed that lint screens must be brushed and cleaned after every load or every hour to prevent them from becoming packed with lint, which could block warm air and raise the temperature in the lint basket, creating a potential fire hazard. Employee #72 acknowledged the overflowing lint traps and recognized the associated fire risk.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to maintain the required Registered Nurse (RN) coverage for eight consecutive hours daily, as mandated by regulations. During a review of staffing posting forms, it was discovered that on March 18, 2023, there was no RN on staff for the entire day. Additionally, on April 9, 2023, the facility only provided 7.83 hours of RN coverage, falling short of the required eight hours. This deficiency was confirmed during an interview with the facility's scheduler, who acknowledged the lack of RN coverage on the specified dates. The absence of adequate RN staffing has the potential to affect all 67 residents currently residing in the facility.
Incomplete Staff Evaluation for CNA
Penalty
Summary
The facility failed to complete a staff evaluation for a Certified Nursing Assistant (CNA) identified as CNA #61. The CNA was hired on May 9, 2024, and the evaluation was conducted by the Director of Nursing (DON) on June 27, 2024. However, a small yellow post-it note was found covering the signature line for CNA #61, indicating that the employee missed going over the review with the DON. During an interview, the Scheduler acknowledged that the evaluation was incomplete and should have been completed with the staff member upon her return to the facility.
Deficiency in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to ensure that kitchen staff served food in a safe and sanitary manner, which had the potential to affect all residents receiving nutrition from the facility's kitchen. During an observation, staff did not properly wash hands with soap and water or wear gloves before handling serving spoons. Specifically, a staff member exited an office without washing hands or wearing gloves and handled serving spoons, which were then passed to another staff member to use in the serving line. This was acknowledged by the staff, who then washed hands, changed gloves, and replaced the serving spoons. Additionally, the facility staff failed to wear beard restraints as required by current food code requirements. Kitchen staff were observed working on the serving line without beard restraints, which was acknowledged, and they subsequently wore the required restraints. The facility's policy for food preparation and kitchen staff attire mandates proper handwashing techniques, glove use, and the wearing of approved attire, including hair nets or caps and facial hair restraints.
Failure to Identify Required Nursing Competencies
Penalty
Summary
The facility failed to identify the necessary Certified Nurse Aide (CNA) and nursing competencies required to meet the care needs of the resident population. During a review of the facility assessment, it was noted that the care areas of the resident population were outlined, and under the section for staffing, training, services, and personnel, the required nursing competencies were marked as sufficient. However, during an interview with the Person in Charge (PIC) and an assisting Administrator, they were unable to identify any specific competencies required for the nursing staff to complete. This deficiency was discovered during a random review of CNA/nursing competencies as part of the long-term care survey process, potentially affecting more than a limited number of residents in a facility with a census of 67.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its Abuse Prohibition policy, which led to multiple incidents involving a male resident with a history of sexual behaviors and aggression. This resident, who has dementia and Alzheimer's disease, was involved in an incident where he was witnessed grabbing the breast of a female resident. Despite being placed on every 15-minute checks following the incident, the facility's records revealed a pattern of escalating behavioral disturbances by this resident, including verbal, physical, and sexual aggression towards other residents and staff. The facility's documentation showed numerous instances where the resident exhibited inappropriate and aggressive behaviors, such as making vulgar comments, threatening other residents, and attempting to touch staff and residents inappropriately. These incidents were not reported to the physician or the resident's Power of Attorney (POA), as required by the facility's policy. Additionally, the facility failed to conduct thorough investigations or follow-up assessments to ensure the safety and psychosocial well-being of the affected residents. Interviews with facility staff revealed a lack of awareness and action regarding the resident's behaviors. The facility's corporate Clinical Lead Nurse acknowledged that no investigations had been performed related to these incidents, and the facility's policy on abuse prohibition had not been implemented. The facility also failed to report these incidents to the appropriate authorities or address them in the Quality Improvement Committee, further highlighting the deficiency in handling and preventing abuse within the facility.
Failure to Report and Investigate Abuse Incidents
Penalty
Summary
The facility failed to report incidents of abuse, neglect, or theft to the appropriate state agencies as required by their policy and procedure entitled, Abuse Prohibition. This failure was identified during a review of facility-reported incidents and staff interviews. Specifically, an incident involving Resident #20 and Resident #22 was not reported appropriately. Resident #20, who has a history of sexual behaviors and inappropriate touching, was witnessed grabbing Resident #22's breast. Despite immediate intervention by staff, the incident was not reported to the necessary authorities as per the facility's policy. Resident #20 has a documented history of escalating behavioral disturbances, including verbal, physical, and sexual aggression towards staff and other residents. Multiple entries in Resident #20's medical record detail incidents of inappropriate behavior, such as making vulgar comments, threatening other residents, and inappropriate touching. Despite these documented behaviors, there was a consistent failure to notify the physician or the resident's Power of Attorney (POA) about these incidents, as required by the facility's policy. Interviews conducted with facility staff revealed a lack of awareness and reporting of sexual abuse incidents. RN #33, who conducted the investigation into the incident involving Resident #20 and Resident #22, failed to interview Certified Nursing Assistants (CNAs) or other staff who might have witnessed abuse. Additionally, the facility's corporate Clinical Lead Nurse acknowledged that no investigations or follow-up assessments were conducted for the incidents documented in Resident #20's progress notes. The facility's failure to implement its Abuse Prohibition policy resulted in a lack of protection for residents from further harm.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate allegations of abuse as per their policy and procedure titled 'Abuse Prohibition.' This deficiency was identified during a review of facility-reported incidents and staff interviews. Specifically, an incident on July 2, 2024, involved a male resident with a history of sexual behaviors inappropriately touching a female resident. Despite the incident being reported to a Licensed Practical Nurse and documented, the facility did not conduct a thorough investigation, as evidenced by the lack of interviews with Certified Nursing Assistants who witnessed the event. The male resident involved in the incident had a documented history of escalating behavioral disturbances, including verbal, physical, and sexual aggression towards staff and other residents. Multiple entries in the resident's medical record detailed inappropriate behaviors, such as making vulgar comments, threatening other residents, and inappropriate touching. Despite these documented behaviors, there was a consistent failure to notify the physician or the resident's Power of Attorney, and no investigations were conducted for these incidents. Interviews with facility staff revealed awareness of the male resident's behaviors, yet the facility's policy on abuse prohibition was not implemented. The facility failed to protect residents from further harm, did not report or investigate incidents as required, and did not notify the physician or family members of the occurrences. Additionally, the facility did not conduct follow-up assessments to evaluate the psychosocial welfare of the affected residents, nor were these incidents addressed in the Quality Improvement Committee.
Expired Medical Supplies Found in Storage
Penalty
Summary
The facility failed to adhere to currently accepted professional principles regarding the management of expired medical supplies. During an observation of the medication and supply storage room, surveyors found two boxes of BD Blood Transfer Devices, each containing 50 devices, with an expiration date that had passed. Additionally, twenty urinary catheters of various sizes and volumes were discovered to be expired. These findings were confirmed by a registered nurse during the survey. This deficiency has the potential to affect more than a limited number of residents in the facility, which has a census of 67.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to provide a substantial and nourishing snack between the evening meal and breakfast, affecting residents without a dietary order for an evening snack or those unable to request snacks due to cognitive or physical limitations. During a resident council meeting, two residents reported not being offered bedtime snacks for several weeks, while two others mentioned having to request snacks from the nurse's station. A review of the facility's Food and Nutrition Service Policies and Procedures indicated that snacks should be delivered to the nursing station at specific times and offered to every resident by nursing or designated staff. An interview with a registered nurse revealed that nurse aides are responsible for taking the snack cart to each room to offer snacks every evening.
Improper Storage of Clean Clothing in Chemical Closet
Penalty
Summary
The facility failed to prevent infections through indirect contact transmission by improperly storing clean resident clothing in the chemical closet of the laundry room. During an observation, it was noted that several items of personal resident clothing were hanging in the chemical closet, which is located on the dirty side of the laundry room where soiled linen is brought for laundering. These clothing items were in direct contact with a Rapid Multi-Surface Cleaner, which is used for mops in the facility. The cleaning solution was also stored on the floor, further increasing the risk of contamination. An interview with an employee revealed that personal resident clothing is hung in this closet after laundering if it is not labeled and cannot be directly delivered to the appropriate resident. The employee stated that staff check this closet when a resident is missing an item. The employee acknowledged the potential for contamination of the clothing by the cleaner stored on the floor.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident during a long-term care survey. This deficiency was observed when a Registered Nurse (RN) was assisting a resident with eating while standing over the resident's bed. The resident had a laptop on the over-the-bed table alongside the dinner tray, and an empty chair was available on the right side of the bed. The Clinical Reimbursement Coordinator RN noted that the assisting RN was new and should not have been standing over the resident. The assisting RN acknowledged the inappropriate action and expressed concern about the laptop's placement, indicating she would move the chair to assist the resident while seated.
Lack of Documentation for Advanced Directive
Penalty
Summary
The facility failed to ensure that a resident had documentation related to the provision of information regarding advanced directives. During a record review, it was found that there was no documentation of an Advanced Directive for the resident. An interview with a staff member confirmed that there was no evidence that the resident or their representative had been provided with information about implementing an Advanced Directive. The staff member mentioned that a call had been made to the resident's representative, who expressed a desire for the resident to remain a Do Not Resuscitate (DNR). A care plan meeting was scheduled to discuss this further with the resident's representative.
Deficiencies in Maintaining a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by observations and staff interviews. In room A1-1, two soiled privacy curtains were observed, one with a brown substance and the other with both a brown substance and red spots. These curtains remained unchanged upon a follow-up observation the next day, which was confirmed by a Registered Nurse and the Corporate Clinical Lead. Additionally, in Unit B, the bedside nightstand in room A was found to have one-third of its top surface laminate torn off, exposing rough edges and particle board underneath. This condition was acknowledged by a Registered Nurse as unsafe for residents due to the potential for skin tears and not conducive to a homelike environment.
Failure to Ensure Anonymous Grievance Reporting
Penalty
Summary
The facility failed to ensure that residents could report grievances anonymously, as discovered during a resident council meeting. Residents expressed their inability to file grievances without revealing their identity. An interview with the admissions director confirmed that there was no system in place for anonymous grievance submission, as grievances were typically handed directly to her or the administrator. A review of the facility's Grievance/Concern policy indicated a responsibility to maintain confidentiality, including for grievances submitted anonymously, highlighting a discrepancy between policy and practice.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's transfer to the hospital, which was identified during a long-term care survey. This deficiency was noted for one of the three residents reviewed for hospitalizations. Specifically, the medical record review for a resident revealed that the resident experienced a change in condition with abnormal vital signs, leading to an order for hospital transfer. However, there was no documentation of notification to the Ombudsman regarding this transfer. During an interview, the Clinical Reimbursement Coordinator (CRC) acknowledged that the notification responsibility fell to the Social Worker, who was on medical leave at the time. The CRC admitted that the notification was not completed, indicating a lapse in the facility's protocol for notifying the Ombudsman in the absence of the designated staff member.
Failure to Notify Resident Representatives of Bed Hold Policy
Penalty
Summary
The facility failed to notify resident representatives of the bed hold policy at the time of transfer or discharge, as required by their policy. This deficiency was identified during a long-term care survey process, where two residents were reviewed for transfers or discharges. For Resident #68, a medical record review revealed that the resident was transferred to the hospital due to a change in condition involving abnormal vital signs. However, the medical record lacked documentation of a bed hold notification to the resident's medical power of attorney. The facility's Admission Director confirmed that the notification was not completed and was unable to provide a reason for this oversight. Similarly, for Resident #51, the medical record review showed that the resident was transferred to the hospital after experiencing vomiting that appeared to be blood. Again, the medical record was missing the required bed hold notification. The facility's Corporate Clinical Lead Nurse acknowledged the omission and stated that the notification should have been completed but did not know why it was not. A review of the facility's policy and procedure on discharge and transfer confirmed the requirement to immediately inform the resident or their representative in writing about the transfer, in a language they understand.
Failure to Coordinate PASSR for Residents with Mental Health Needs
Penalty
Summary
The facility failed to coordinate with the appropriate State-designated authority to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate to their needs when completing or revising a Pre-Admission Screening and Resident Review (PASSR). This deficiency was identified during a long-term care survey process for three residents. For Resident #57, the PASSR did not include several medical diagnoses such as Schizoaffective Disorder Bipolar Type, Delirium, Major Depressive Disorder, and Anxiety Disorder, which were confirmed by the Admissions Director as necessary to be included. Similarly, Resident #43's PASSR was missing diagnoses of Post Traumatic Stress Disorder, Paranoid Schizophrenia, and Delusional Disorders, which were also confirmed by the Admissions Director. For Resident #16, the PASSR lacked documentation of Post Traumatic Stress Disorder and Bipolar Disorder, as acknowledged by the facility's Corporate Clinical Lead Nurse. These omissions indicate a failure to accurately complete and update the PASSR forms, which are crucial for ensuring appropriate care and services for residents with specific mental health needs.
Failure to Monitor PTSD Triggers in Resident
Penalty
Summary
The facility failed to monitor potential triggers for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). This deficiency was identified during a review of the resident's medical record, which revealed that the resident had multiple diagnoses, including PTSD, unspecified dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, and major depressive disorder. Despite these diagnoses, the resident's care plan did not include any specific interventions or monitoring related to PTSD. Additionally, the medication administration record showed no behavior monitoring for the psychotropic medications prescribed to the resident. The facility's policy on behavior management and trauma-informed care requires staff to identify and document behavioral symptoms and potential triggers for residents with a history of trauma. However, the facility did not assess the resident for potential triggers or implement trigger-specific interventions. The Corporate Clinical Lead Nurse acknowledged the absence of a care plan for PTSD and the lack of assessment for potential triggers, indicating a failure to adhere to the facility's policies and procedures.
Failure to Revise Care Plans for Changing Resident Needs
Penalty
Summary
The facility failed to revise the care plan for Resident #25 when their care needs changed. Initially, the care plan created on 11/16/23 indicated that Resident #25 was insulin-dependent. However, the resident's Lantus insulin was discontinued on 07/25/24, and the care plan was not updated to reflect this change. This oversight was confirmed by the Corporate Clinical Lead on 07/31/24. Similarly, the care plan for Resident #44 was not updated to reflect her current condition. Observations on 07/29/24 showed that Resident #44, a hospice resident since 06/18/24, was frail, bed-bound, and at the end of life. Despite this, the care plan included activities and goals that were not appropriate for her current state, such as attending out-of-room activities and maintaining the ability to feed herself. This discrepancy was also confirmed by the Corporate Clinical Lead on 07/31/24.
Failure to Report Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to adhere to physician orders regarding the reporting of elevated blood glucose levels for a resident. The resident had specific orders to monitor blood sugars twice weekly and notify the physician if levels were below 60 mg/dl or above 300 mg/dl. Despite this, there were multiple instances where the resident's blood glucose levels exceeded 300 mg/dl, specifically on four consecutive days, and these were not reported to the physician as required. This oversight was confirmed by the Corporate Clinical Lead, who acknowledged that the elevated levels should have been communicated to the physician.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was incontinent of bladder. On the morning of July 29, 2024, the resident indicated that they were incontinent and had used the call bell to alert staff for assistance. However, a staff member turned off the call bell and informed the resident that they would return after the lunch trays were picked up. The resident was left waiting for incontinence care, which was only provided after the surveyor intervened and informed the staff member responsible for the resident's care. The staff member, Employee #43, acknowledged the resident's need for care but stated that incontinence care was not provided during meal times due to a restriction on having linen carts in the hallway simultaneously with meal carts. This practice was not supported by any facility policy, as confirmed by the facility's Corporate Clinical Lead Nurse. The nurse acknowledged that the resident should have received prompt care when requested, indicating a lapse in the facility's care procedures.
Failure to Monitor PTSD Triggers and Implement Care Plan
Penalty
Summary
The facility failed to monitor potential triggers for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). This deficiency was identified during a review of the medical record of a resident who had multiple diagnoses, including PTSD, unspecified dementia with behavioral disturbance, schizoaffective disorder, bipolar disorder, and major depressive disorder. The resident was prescribed psychotropic medications, including Fluphenazine and Seroquel, but there was no behavior monitoring documented in the medication administration record (MAR) for these medications or the associated diagnoses. Additionally, the resident's care plan did not include any specific interventions related to their PTSD. The facility's policy on trauma-informed care requires the identification of triggers that may re-traumatize residents and the implementation of trigger-specific interventions, which should be included in the care plan. However, the facility failed to assess the resident for potential triggers and did not develop a care plan addressing the PTSD diagnosis. This oversight was acknowledged by the facility's Corporate Clinical Lead Nurse during an interview.
Deficiency in Social Services for Discharge Planning and Decision Making
Penalty
Summary
The facility failed to provide necessary social services for discharge planning and appointment of a healthcare decision maker for two residents. Resident #62 expressed a desire to be discharged and live independently but required assistance in securing housing. The resident had been without a social worker for several months, and the last documented social services notes were from March 2024. These notes indicated that the social worker was assisting with discharge planning, including housing applications and social security benefits. However, since the social worker's absence, there was no follow-up, leaving the resident without the necessary support to transition out of the facility. Resident #48 experienced a change in capacity status, regaining capacity temporarily before losing it again. Despite this change, the facility did not promptly appoint a healthcare decision maker. The resident's niece, who had previously served as a surrogate, was not contacted to resume this role until after surveyor intervention. The delay in appointing a decision maker left the resident without a designated person to make medical decisions during the period of incapacity. The facility's lack of a social worker due to medical reasons contributed to these deficiencies. The admissions department, which was not equipped with licensed social workers, attempted to fill the gap but was unable to provide the necessary support for discharge planning and decision-making processes. This resulted in inadequate social services for the residents involved, impacting their ability to transition out of the facility and manage their healthcare decisions effectively.
Failure to Monitor Behaviors for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to monitor behaviors for a resident receiving psychotropic medication, which was identified during a Long Term Care Survey Process. The deficiency was noted for one resident, identified as Resident #16, out of five residents reviewed for unnecessary medications. Resident #16 had multiple diagnoses, including Post Traumatic Stress Disorder, Unspecified Dementia, Schizoaffective Disorder, Bipolar Disorder, and Major Depressive Disorder, all dated 03/20/24. The resident was prescribed Fluphenazine and Seroquel for schizoaffective disorder, but there was no evidence of behavior monitoring in the medication administration record. The facility's policy on behavior management requires staff to monitor and document any exhibited behavioral symptoms in the medical record. However, upon review, it was found that there was no documentation of behavioral monitoring for Resident #16. The facility's Corporate Clinical Lead Nurse acknowledged the lack of documentation and confirmed that behavioral monitoring should have been recorded in the resident's medical record.
Incomplete Medical Record for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate, as identified during a Long Term Care Survey. The resident, who had multiple diagnoses including Post Traumatic Stress Disorder (PTSD), unspecified dementia, schizoaffective disorder, bipolar disorder, and major depressive disorder, was receiving psychotropic medications for schizoaffective disorder. However, the facility's Social Worker did not document the PTSD diagnosis in the resident's Social Determinants of Health assessment. Additionally, the resident's care plan lacked any reference to the PTSD diagnosis. The facility's Corporate Clinical Lead Nurse acknowledged the inaccuracy in the resident's assessment.
Inaccurate and Inaccessible Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information in a prominent location, as required. During a tour of the front entrance, it was observed that the staffing posting form was not visible for residents and visitors. The Admissions Director acknowledged that the form should be posted at the front of the building for easy access. Instead, it was located at the Director of Nursing's office, which is not a prominent location accessible to all residents and visitors. Additionally, the facility's staffing posting forms contained missing and inaccurate data. On several occasions, the forms inaccurately reported the number of direct care Certified Nursing Assistants (CNAs) and Registered Nurses (RNs), as well as their hours. The forms also used decimals to represent staff numbers, which did not accurately reflect the total direct care staff. Furthermore, the census was missing on multiple forms, and administrative nursing staff hours were incorrectly included as direct care hours. The facility Scheduler confirmed these discrepancies and acknowledged the errors in the staffing data.
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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