Princeton Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Princeton, West Virginia.
- Location
- 315 Courthouse Rd., Princeton, West Virginia 24740
- CMS Provider Number
- 515187
- Inspections on file
- 18
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Princeton Health Care Center during CMS and state inspections, most recent first.
Surveyors found that multiple residents did not have water pitchers, [NAME] cups, or other drinks at bedside, with some having only leftover juice from lunch, despite facility policies requiring fresh bedside water and a structured hydration program. One resident complained of feeling very hot and repeatedly requested a drink, and an LPN and a NA confirmed that several residents lacked bedside water. The facility’s written procedures assigned night shift staff to replace used water containers daily with clean, filled containers, and dietary staff to wash and supply pitchers, yet these processes did not result in consistent bedside hydration for the affected residents.
The facility failed to maintain an effective infection prevention and control program, with 29 missed hand hygiene opportunities out of 193 observations and one missed during a medication pass. The Infection Preventionist acknowledged the lack of immediate education for staff and could not provide documentation of corrective actions.
A facility failed to protect residents from abuse, specifically misappropriation of medication, affecting three residents. Narcotic medications were borrowed by LPNs from one resident to administer to another, against protocol. The LPNs involved cited issues with obtaining medications as reasons for their actions. Residents did not express distress or miss doses due to these incidents.
The facility failed to timely revise comprehensive care plans for two residents receiving 1:1 care interventions. One resident had a 1:1 sitter after a fall, which was not documented in the care plan, while another had ongoing 1:1 care not timely reflected in the care plan. The DON and QAN acknowledged these oversights during the survey.
The facility failed to provide person-centered care by not adequately documenting and managing the use of one-on-one sitters for residents who had experienced falls. A resident had a Health Team Aide providing one-on-one care 24 hours a day since a fall, yet there was no physician's order for this intervention, and it was not included in the resident's care plan. Similarly, another resident was observed with a staff member sitting with her after a fall, but this was not documented in the care plan. The lack of documentation and formal assessment of the need for one-on-one sitters indicates a deficiency in the facility's approach to individualized resident care and safety management.
The facility failed to ensure accurate and current Daily Staffing Posting information, with discrepancies in reported staff numbers and hours worked. The forms were not posted in a prominent place accessible to residents and visitors. The Administrator acknowledged these inaccuracies and the improper posting location.
The facility failed to ensure cooking pans were dry before storage, leading to wet nesting, and improperly stored a hot/cold compress pack in the resident pantry refrigerator. This was confirmed by a Certified Dietary Manager and an LPN during a kitchen tour and pantry inspection.
The facility failed to provide a dignified dining experience by not serving residents seated together at the same time. Two residents were observed sitting together, but one had to wait three minutes to be served while the other ate. A CNA explained that a mix-up with the meal ticket led to this situation, and the administrator confirmed the error.
A facility failed to obtain informed consent for a psychotropic medication prescribed to a resident for inappropriate sexual behaviors related to unspecified psychosis. During a medical record review, it was found that the resident was prescribed aripiprazole 20 mg without documented informed consent. The DON confirmed the absence of informed consent during an interview.
A resident's medical information was compromised when a sign indicating an allergy to Latex was posted behind their bed, visible from the hallway. This violated the facility's confidentiality policy, which prohibits leaving personal or medical information viewable by unauthorized persons. The administrator acknowledged the privacy breach.
A strong unpleasant odor was detected in a resident's room during a survey, persisting over several days. An LPN suggested it might be due to soiled undergarments, but the Administrator later identified the PTAC unit as the source. Despite efforts, the odor remained unresolved.
The facility did not notify the Ombudsman of a resident's discharge to the hospital. Although the social worker stated that notification was made, no verification could be provided.
The facility did not update the PASARR for two residents with new or possible serious mental disorders. For one resident, the PASARR was outdated and not revised after a new diagnosis of delusions. The social worker confirmed the lack of an updated PASARR.
The facility failed to ensure that the PASARR for two residents accurately reflected their pre-admission diagnoses. For one resident, the PASARR did not include the diagnosis of unspecified psychosis, which was part of the admitting diagnosis. This discrepancy was confirmed during a record review and verified in an interview with the Social Services/Admissions Director.
The facility failed to develop comprehensive care plans for two residents. One resident, with traumatic brain disorder and dementia, was discharged without a care plan focus on discharge planning, despite arrangements for medical equipment and home health visits. Another resident, diagnosed with a psychotic disorder with delusions, lacked a care plan for this condition. The DON acknowledged the oversight and requested corrections.
The facility failed to obtain physician orders for 1:1 interventions for two residents at high risk for falls. One resident had a 1:1 sitter after a fall, but this was not documented in the care plan, and no physician order was obtained. Another resident received 1:1 care 24 hours a day due to frequent falls, but there was no physician order, and the intervention was not included in the care plan for falls. The DON acknowledged the lack of documentation and policy regarding 1:1 interventions.
A resident with PTSD did not receive adequate trauma-informed care, as the facility failed to identify and manage potential triggers since the last assessment in 2021. Despite a care plan, there was no follow-up on the resident's increased medication for tearfulness, and the DON confirmed the lack of recent assessments.
A facility failed to perform a scheduled hemoglobin A1c test for a resident on Ziprasidone, a medication that can elevate blood sugar levels. The test, ordered every six months, was last conducted several months ago, as confirmed by the DON during a survey.
The facility failed to maintain accurate medical records for two residents. One resident's MDS indicated PTSD, but it was not listed in their medical diagnoses, despite having a trauma care plan. Another resident's POST form lacked the physician's contact number, which was acknowledged by the social worker. These deficiencies were identified during the LTC survey process.
Failure to Provide Bedside Hydration Consistent With Resident Needs and Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents consistently had access to drinks at bedside in accordance with their needs, preferences, and the facility’s hydration policies. During surveyor observations, multiple residents were found without water pitchers, [NAME] cups, or any water at their bedside. One resident explicitly stated feeling very hot and repeatedly requested a drink, and an LPN confirmed that this resident had no drinks at bedside. Another resident and that resident’s roommate were also observed without any drinks at bedside, which the LPN again confirmed. A nursing assistant later verified that several additional residents had no water or water pitchers at bedside, with some having only leftover juice in Kennedy cups from lunch. The facility’s written Hydration Program policy stated that each resident should receive sufficient fluid intake to maintain proper hydration and health, and the Bedside Water Containers policy required that residents have fresh drinking water at bedside daily, with two complete water container sets per resident. The procedure assigned night shift staff to collect used water containers and replace them daily with clean containers filled with fresh water and ice, which were to be cleaned and sanitized by the food and nutrition services department and then stored inverted until needed. The Dietary Manager reported that water pitchers are replaced and washed in the morning, with dietary staff delivering clean pitchers early and other staff distributing ice and water. The Administrator reported that the facility conducts a hydration pass twice a day. Despite these policies and processes, survey findings showed that several residents did not have water or appropriate bedside fluids available at the time of observation.
Infection Control Deficiency Due to Missed Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which is essential for providing a safe, sanitary, and comfortable environment and preventing the transmission of communicable diseases. Specifically, there were 29 missed opportunities for hand hygiene out of 193 documented observations, as well as one missed opportunity during a medication pass observed during the long-term survey process. These missed opportunities occurred over several dates in February, March, and April of 2024. During an interview, the Infection Preventionist acknowledged the lack of immediate education for staff who missed hand hygiene opportunities and was unable to provide documentation of any corrective education provided.
Misappropriation of Medication in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from abuse, specifically misappropriation of medication, affecting three residents. The issue was identified during an in-house audit conducted by the facility. It was found that narcotic medications were borrowed from one resident to administer to another, which is against the facility's protocol. This occurred multiple times for the residents involved, with one resident having their medication borrowed five times, another once, and the third resident twice. The incidents involved Licensed Practical Nurses (LPNs) who borrowed medications due to various reasons, such as the inability to obtain the medication from the pharmacy or issues with the medication dispensing system. The LPNs involved provided verbal and written statements acknowledging their actions and the reasons behind them. They believed they were acting in the best interest of the residents in pain, although this was not in line with the facility's procedures. Interviews with the residents involved revealed that they did not express any distress or mental anguish due to the incidents. The residents were described as pleasant, comfortable, and without voiced needs or concerns during the social worker's visits. The facility's management confirmed the incidents and acknowledged that the residents did not miss any doses of their medication due to the borrowing of narcotics.
Failure to Revise Comprehensive Care Plans Timely
Penalty
Summary
The facility failed to revise the comprehensive care plans for residents in a timely manner, leading to deficiencies in care planning. Resident #47 was observed with a black eye and had a 1:1 sitter intervention in place following a fall, which was not documented in the care plan. The resident had a history of falls and was identified as high risk due to confusion, deconditioning, and poor safety awareness. Despite the intervention being implemented, it was not included in the care plan, and the Director of Nursing acknowledged this oversight during an interview. Similarly, Resident #75 had a Health Team Aide providing 1:1 care, which was not timely reflected in the care plan. The intervention was documented in the medical record dating back several months, but the care plan was only updated recently. The Quality Assurance Nurse confirmed that the care plan had not been revised in a timely manner to reflect the ongoing 1:1 care. These findings indicate a failure to update and revise care plans to include necessary interventions for residents, as observed during the survey process.
Deficiency in Person-Centered Care and Documentation for Fall Interventions
Penalty
Summary
The facility failed to provide person-centered care by not adequately documenting and managing the use of one-on-one sitters for residents who had experienced falls. Resident #75 had a Health Team Aide (HTA) providing one-on-one care 24 hours a day since a fall on 09/18/23, yet there was no physician's order for this intervention, and it was not included in the resident's care plan for falls. The Director of Nursing (DON) acknowledged that the Interdisciplinary Team (IDT) determines the appropriateness of one-on-one sitters without a physician's order and without documenting the review process. Additionally, the facility's Social Worker did not routinely assess the psychosocial well-being of residents receiving one-on-one sitters, and there was no documentation of such an assessment for Resident #75. Similarly, Resident #47 was observed with a staff member sitting with her after a fall on 05/03/24, which resulted in a black eye and other minor injuries. Despite the use of a one-on-one sitter as an intervention, this was not documented in the resident's care plan. The DON confirmed that the IDT had not yet met to discuss the fall or the continued use of the one-on-one sitter for Resident #47. The lack of documentation and formal assessment of the need for one-on-one sitters indicates a deficiency in the facility's approach to individualized resident care and safety management.
Inaccurate and Inaccessible Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the Daily Staffing Posting information was accurate and current, as identified during a long-term care survey. The Daily Staffing Posting Form was not posted in a prominent place readily accessible to residents and visitors. Additionally, the form did not accurately reflect the direct care staff, nor did it identify the actual number of staff and the actual hours worked. This deficiency was observed during the survey process of reviewing the sufficiency and competency of nursing staff, potentially affecting more than a limited number of residents and visitors. During the review of the Daily Staffing Posting Forms with the Administrator, it was found that the total number of Registered Nurses (RNs) for direct care staff was inaccurately reported. The Administrator admitted that RNs with administrative duties were included in the RN direct care staff count because they occasionally assisted floor staff. However, according to the Centers for Medicare & Medicaid Services guidelines, staffing should be reported based on the employee's primary role. The Administrator acknowledged that the RN staffing totals and hours worked were not accurate. Further discrepancies were identified in the Staffing Posting Forms for several dates, where the reported numbers of staff and hours worked did not match the actual numbers from the Detail Hours Overview report. For example, on one date, the form reported nine Certified Nursing Assistants (CNAs) working 103.5 hours, while the actual numbers were ten CNAs working 112 hours. Similar inaccuracies were found for Licensed Practical Nurses (LPNs) and RNs across multiple dates. The Administrator agreed that the forms did not reflect the total number of staff or the actual hours worked. Additionally, it was noted that the Daily Staffing Posting Form was not posted in a location easily accessible to residents and visitors, which the Administrator also acknowledged.
Improper Storage of Kitchen Equipment and Medical Supplies
Penalty
Summary
The facility failed to ensure that cooking and serving pans were completely dry before storing them, resulting in wet nesting. During an initial kitchen tour, it was observed that pans were stacked under the counter, and one was found to be wet on the right side. This was confirmed by the Certified Dietary Manager, who acknowledged that staff should have ensured the pans were dry before stacking and storing them. Additionally, a hot/cold compress pack was improperly stored in the resident pantry refrigerator, where cold snacks are kept. This was discovered during an inspection of the facility's North Pantry. A Licensed Practical Nurse confirmed that the hot/cold pack should not have been in the pantry freezer, indicating that there is a designated fridge behind the nurses' station for such items.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents by not serving them simultaneously when seated together. On May 8, 2024, at 12:20 PM, in the South Dining room, two residents were observed sitting together at one table, while another resident sat alone at a different table. At 12:25 PM, one resident at the first table was served first, followed by the resident at the second table at 12:26 PM. The second resident at the first table had to wait three minutes while the first resident ate, and was only served at 12:29 PM. A staff interview with a CNA revealed that there was a mix-up with the meal ticket, leading to the decision to serve the resident at the second table to prevent their food from getting cold. The facility administrator confirmed that the second resident at the first table should have been served with or after the first resident, and not left waiting while the other resident at the same table ate.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the use of a psychotropic medication for a resident. During a medical record review, it was discovered that a resident was prescribed aripiprazole 20 mg tablet for inappropriate sexual behaviors related to unspecified psychosis. However, there was no informed consent documented for the use of this psychotropic medication. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of informed consent for the medication prescribed to the resident.
Privacy Breach of Resident's Medical Information
Penalty
Summary
The facility failed to protect the privacy and confidentiality of a resident's medical information. During an observation, a sign was found posted behind a resident's bed indicating an allergy to Latex, which was visible from the hallway when the door and curtain were open. A record review confirmed the resident's allergy to Latex. The facility's policy on confidentiality states that personal or medical information should not be left unattended or viewable by unauthorized persons. The administrator confirmed that the sign infringed on the resident's privacy.
Unpleasant Odor in Resident's Room
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by a strong unpleasant odor observed in a resident's room during a long-term care survey. The odor was first noted during a tour of the 200 hall and persisted over several days. A Licensed Practical Nurse (LPN) suggested that the odor might be due to a resident placing soiled undergarments in drawers. However, the Director of Nursing (DON) and the Administrator later identified the smell as emanating from the packaged thermal air conditioner (PTAC) unit. Despite efforts to address the issue, the odor remained unresolved at the time of the report.
Failure to Notify Ombudsman of Resident's Hospital Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's discharge to the hospital. This deficiency was identified during a record review and staff interview. The resident was discharged to the hospital on December 6, 2024, at 12:48 pm. During an interview on May 6, 2024, the social worker claimed that the Ombudsman was notified of the discharge but could not provide verification of this notification.
Failure to Update PASARR for Residents with New Diagnoses
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program under Medicaid for residents with newly evident or possible serious mental disorders. This deficiency was identified for two out of six residents reviewed during the long-term care process. Specifically, for one resident, the PASARR was dated over a year prior to the updated diagnosis of delusions due to a known physiological condition, and no subsequent PASARR was completed following this diagnosis. During an interview, the social worker acknowledged the absence of an updated PASARR for the resident's new diagnosis.
PASARR Screening Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) for two residents accurately reflected their pre-admission diagnoses. Specifically, for Resident #80, the PASARR did not include the diagnosis of unspecified psychosis not due to a substance or known physiological condition, which was part of the admitting diagnosis on 06/16/22. This discrepancy was confirmed during a record review on 05/07/24 and verified in an interview with the Social Services/Admissions Director on 05/08/24.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a complete and accurate comprehensive care plan for two residents. For the first resident, who had been living at the facility since 2022 and was discharged to a family member's home, the care plan did not include a focus on discharge planning. Despite the resident having diagnoses of traumatic brain disorder and dementia, and receiving discharge planning assistance from a state agency, the care plan was not updated to reflect the discharge process. The RN Case Manager confirmed that no focus on discharge planning was developed, even though arrangements for durable medical equipment, home health agency visits, and an appointment with the primary care provider were made prior to discharge. For the second resident, diagnosed with a psychotic disorder with delusions due to a known physiological condition, the facility did not develop a care plan for this diagnosis. The diagnosis was identified during a medical record review, and it was noted that the care plan had not been developed since the diagnosis was made. The Director of Nursing acknowledged the oversight and requested that the social worker make the necessary corrections.
Failure to Obtain Physician Orders for 1:1 Interventions
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not obtain physician orders for one-on-one (1:1) interventions for residents who were at high risk for falls. Resident #47 was observed with a black eye and had a 1:1 sitter after a fall, but this intervention was not documented in the care plan, and no physician order was obtained. The Director of Nursing (DON) acknowledged that the Interdisciplinary Team (IDT) had not yet reviewed the fall or obtained a physician order for the 1:1 sitter. Similarly, Resident #75 had a Health Team Aide (HTA) providing 1:1 care 24 hours a day due to frequent falls, but there was no physician order for this intervention. The resident's care plan for falls did not include the 1:1 sitter intervention, although it was noted in the behavioral care plan. The DON stated that the IDT determines the appropriateness of 1:1 sitters but does not document the review process, and the facility lacks a policy regarding the duration of 1:1 interventions.
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 Syndrome (PTSD). The resident, who has a history of trauma from a car accident, multiple strokes, brain aneurysms, and personal losses, was not assessed for PTSD triggers since October 2021. Despite having a care plan that included interventions such as ensuring safety, engaging in comforting activities, and identifying possible triggers, there was no evidence of follow-up or identification of specific triggers for the resident's PTSD. During the survey, it was noted that the resident experienced frustration and tearfulness, which led to an increase in medication without any documented follow-up to assess the effectiveness of this change. The Director of Nursing confirmed the lack of a recent Trauma Informed Care Assessment and acknowledged the oversight. The absence of a comprehensive approach to managing the resident's PTSD, including the identification and management of triggers, contributed to the deficiency identified during the survey.
Failure to Perform Scheduled Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory services as ordered by the physician for a resident, which constituted a deficiency. The resident had a physician's order for a hemoglobin A1c (HgbA1-c) test to be performed every six months. This test is crucial for monitoring average blood sugar levels over the past three months, especially since the resident was on Ziprasidone (Geodon) for psychosis, a medication known to potentially elevate blood sugar levels. Upon review, it was found that the last HgbA1-c test was conducted on 09/07/23, indicating that the test was not performed as per the six-month schedule. The Director of Nursing confirmed the oversight during the survey, acknowledging that the test had not been conducted as ordered.
Deficiencies in Medical Record Accuracy and POST Form Completion
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents during the Long-Term Care Survey Process. For one resident, the Minimum Data Set (MDS) indicated a diagnosis of Post Traumatic Stress Syndrome (PTSD), but this diagnosis was not listed in the resident's medical records, although there was a care plan for trauma. The Director of Nursing confirmed the discrepancy during an interview but did not provide further information by the end of the survey. For another resident, the Physician Orders for Scope of Treatment (POST) form was incomplete, lacking the contact number of the physician who signed the order. This omission was acknowledged by the social worker during an interview. The absence of the contact number could hinder communication with the physician regarding any errors in the form, as per the 2021 POST form guidance.
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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