Putnam Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hurricane, West Virginia.
- Location
- 300 Seville Road, Hurricane, West Virginia 25526
- CMS Provider Number
- 515070
- Inspections on file
- 24
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Putnam Center during CMS and state inspections, most recent first.
Surveyors identified a strong, unpleasant odor throughout the building on multiple occasions, which was confirmed by a Corporate RN. The facility's cleaning policy emphasizes maintaining a safe and hygienic environment, but the observed conditions did not meet these standards.
Two residents did not receive incontinence care for several hours, despite reporting the issue to a nursing assistant during lunch. The assigned NA was observed using her personal phone and attending to other residents, while another NA was redirected before completing care and did not inform others of the unmet needs. The facility's investigation, upon review, confirmed the neglect based on witness and resident statements.
Surveyors found that several dependent residents did not consistently receive scheduled showers or bed baths, with significant gaps in care and missing documentation. Interviews with residents, family, and staff, as well as review of care plans, revealed that showers were missed due to staff changes and lack of follow-through, and that there was no written policy for bathing frequency. The DON confirmed that expected care and documentation were not consistently provided.
The facility did not clarify physician orders for oral medications for residents with NPO status, resulting in documentation of oral medication administration during periods when residents were not to receive anything by mouth. Additionally, a newly admitted resident did not receive required CPAP equipment upon arrival, and necessary orders and care planning were not initiated before discharge. These actions and inactions were confirmed through record review and interviews.
The facility did not ensure that the pharmacist reported medication regimen irregularities for three residents with NPO orders, resulting in oral medications being ordered and documented as administered despite NPO status. The pharmacist's reviews did not identify or report these discrepancies, and the required notifications to the attending physician, medical director, and DON were not made.
The facility did not ensure accurate medical records and physician orders for several residents, including discrepancies in fall intervention documentation and the administration of oral medications to residents with NPO orders. Although leadership stated that medications were given via tube, the records indicated oral administration, and care plans did not match physician orders for fall prevention.
Two residents did not receive timely incontinence care, with one found in a soiled and disintegrated brief and exhibiting skin redness. Staff failed to communicate care needs, and documentation confirmed a new wound consistent with incontinence-associated dermatitis. Witness and resident statements verified the neglect.
A resident's care plan was not updated to include all current fall interventions, such as 1:1 supervision, floor mats, and bed placement, despite these measures being in place and ordered. The care plan only listed a low bed with a parameter mattress, and omissions were confirmed by the DON and a corporate RN.
A medication tube was found at the bedside of a resident, presenting an accident hazard due to inadequate supervision and failure to maintain a hazard-free environment. The medication was discovered on the nightstand during a survey and was removed after staff notification.
A nurse dropped a cup lid on the floor, picked it up, and proceeded to use it to serve a drink to a resident without replacing it, until prompted by a surveyor. The DON acknowledged the lapse in maintaining a sanitary eating environment, and the nurse involved admitted to not realizing the mistake at the time.
Surveyors observed unclean floors, full trash cans, and personal items obstructing housekeeping, along with stained ceiling tiles and an open attic trap door allowing hot air into the building. Multiple beds were left unmade due to a shortage of linens, with the linen closet found empty and staff confirming ongoing supply issues. The administrator verified these deficiencies during the walkthrough.
Several residents were found without access to fresh water or fluids at their bedside, with some reporting infrequent water delivery and having to wait until meals for drinks. Staff interviews confirmed that water and ice were not consistently provided as required, resulting in inadequate fluid intake for residents.
A resident was found without physician-ordered heel boots intended to prevent pressure ulcers. Upon inquiry, a NA was unable to explain the omission, later retrieving and applying the boots after confirming the resident's preference. The absence of the heel boots was confirmed by both the NA and the DON.
Multiple residents were found living in unsanitary conditions, including bathrooms with soiled briefs and dried substances, rooms with spilled food and fluids that attracted ants, and hallways littered with trash and sticky puddles. Staff and RNs acknowledged these issues, which persisted throughout the day and did not meet standards for a clean, homelike environment.
A resident reported and was observed receiving cold meals, with food temperatures measured below the facility's required standard. The resident stated that this was a common issue, especially at breakfast and dinner, and that food carts were left out before delivery, resulting in unpalatable and improperly heated meals.
Surveyors identified that two residents' CPAP masks were repeatedly left on bedside tables instead of being stored in designated plastic bags, as required for infection control. Another resident's catheter bag and tubing were found lying on the floor, and a clean linen cart was observed uncovered in a hallway. These incidents were confirmed by nursing staff and the IP Nurse, demonstrating failures to follow established infection prevention protocols.
A resident was left uncovered and exposed to passersby due to an open door and undrawn privacy curtain, with catheter tubing visible. An IP nurse entered the room without knocking and only addressed the resident's need for coverage after observing his exposed state.
Two residents did not receive bathing care according to their documented preferences for showers, with one receiving mostly bed baths instead of scheduled showers and another receiving only a few showers despite multiple opportunities and no documented refusals for most missed showers. Both residents' care plans indicated a preference for showers, which was not consistently honored.
A resident was given PRN Ativan orders that exceeded the 14-day limit without documented physician review or rationale, and non-pharmacological interventions were not attempted or documented before administering the medication, despite care plan requirements. The DON confirmed these lapses in both medication review and intervention documentation.
The facility did not follow care plan interventions for two residents: one was given PRN Ativan without documented non-pharmacological interventions for anxiety and psychosis, and another, who is visually impaired, did not consistently receive individualized activity adaptations or one-to-one engagement as outlined in her care plan. These deficiencies were confirmed through record review and staff interviews.
A resident with significant vision impairment was repeatedly observed in bed without stimulation or engagement, despite a care plan specifying adaptive activities and one-to-one visits. Activity participation records showed minimal involvement, and the Activity Director acknowledged the decline in participation had not been addressed.
Surveyors found that the facility did not follow physician orders and protocols for several residents, including failure to repeat a lab test for one resident with elevated ammonia, not implementing the hypoglycemia protocol for another resident with low blood glucose, and not administering medications on time for a third resident. These deficiencies were confirmed by facility leadership.
A resident did not receive the correct prescription reading glasses as ordered by an Ophthalmologist, despite having an eye exam and prescription. Instead, the resident was given glasses that did not match the prescribed specifications, resulting in continued difficulty seeing.
A mattress was observed lying on the floor in a resident hallway, in front of the mechanical room and kitchen/service hall entrance. Both a nurse aide and an RN acknowledged the mattress was a hazard and should not have been left there, as it could have caused a resident to fall.
Two residents were not offered sufficient fluids to maintain proper hydration, as evidenced by empty bedside cups and resident reports of difficulty obtaining water. The Administrator confirmed that these residents did not receive adequate hydration on the day observed.
A resident with poor dentition and ongoing oral discomfort did not receive routine dental services as required, despite being identified as needing dental care in their care plan and MDS assessment. The resident missed a scheduled dental appointment and was not rescheduled for future visits, resulting in no dental consults since admission, contrary to facility policy.
A resident who experienced multiple falls did not have properly completed post-fall neurological assessments, with missing signatures and incorrect or absent dates on the documentation. The administrator and DON confirmed that the required medical record entries were not completed accurately, resulting in a failure to maintain records according to professional standards.
A resident was unable to turn the over-bed light on or off independently because the light switch string was too short to reach. The DON confirmed the inaccessibility of the light string during observation.
The facility did not update care plans for several residents to include current fall prevention interventions, such as call light accessibility and non-skid equipment, and failed to accurately reflect dietary restrictions for a resident who could not tolerate cold or hot foods and beverages. These deficiencies were confirmed through record reviews and staff interviews.
A resident with a history of psychiatric disorders and physical aggression physically assaulted a nonverbal resident, resulting in facial injuries. Despite documented behavioral risks and interventions such as frequent monitoring and psychiatric consultation, the aggressive resident was able to harm another resident, indicating a failure to prevent resident-to-resident abuse.
Failure to Prevent and Address Pervasive Odors in Facility
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment by not preventing strong, unpleasant odors throughout the building. On two separate occasions, state surveyors observed and identified a pervasive odor during their initial entrance and subsequent rounds in the facility. The Corporate Registered Nurse confirmed the presence of the odor when interviewed by the surveyors and indicated awareness of the issue. The facility's own policy and procedure for resident room cleaning and floor care emphasized the commitment to providing a safe and hygienic environment, yet the observed conditions did not align with these standards.
Failure to Investigate and Address Alleged Neglect of Incontinence Care
Penalty
Summary
The facility failed to thoroughly investigate allegations of neglect involving two residents who reported not receiving incontinence care from 5:00 AM until 1:00 PM on the same day. The residents informed a nursing assistant (NA) during lunch tray delivery, who then enlisted another NA to assist with their care. The assigned NA was observed using her personal phone at the nurses' station and rounding on other residents, while another NA stated she was directed to the dining room before completing care for her last residents and did not notify others about the outstanding incontinence care needs. Review of the facility's investigation revealed that, despite the termination of the assigned NA and the investigation being initially marked as unverified, witness and resident statements did confirm the neglect occurred.
Failure to Provide and Document ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically bathing, to residents who were dependent on staff for this care. One resident reported not receiving scheduled showers for extended periods, including an 11-day and a 7-day gap, and staff interviews confirmed lapses in providing showers due to shift changes and lack of follow-through. Documentation review showed that another dependent resident had no record of showers for an entire month and only one shower documented the following month, with missing documentation for both showers and bed baths on multiple days. The DON acknowledged the absence of a written policy regarding the frequency of showers or bed baths, although staff were expected to offer showers twice weekly and bed baths daily, with refusals to be documented. A third resident, also dependent for bathing, was reported by a family member as not receiving enough showers, and the DON was unable to find documentation of any refusals for this resident. Review of care plans and shower schedules confirmed that scheduled showers were not consistently provided or documented. These findings were based on resident and staff interviews, as well as review of care plans and documentation, and affected three residents in a facility with a census of 116.
Failure to Clarify NPO Medication Orders and Provide Timely Respiratory Equipment
Penalty
Summary
The facility failed to ensure continuity of care by not seeking clarification from physicians regarding oral medication orders for residents who were designated as NPO (nothing by mouth), and by failing to obtain necessary respiratory equipment for a newly admitted resident. For multiple residents, there were active NPO orders in place, yet the Medication Administration Records showed that oral medications were documented as administered during the NPO period. In some cases, the Director of Nursing (DON) stated that medications were given via tube, but the orders and documentation did not reflect this clarification, nor was there evidence of provider or pharmacy consultation as required by facility policy. Additionally, the facility did not conduct monthly reviews of orders by nursing staff, leaving them for physician signature without further verification. A newly admitted resident with a hospital order to continue home CPAP therapy for obstructive sleep apnea did not receive the required respiratory equipment upon arrival. The DON was uncertain if the CPAP order was included in the admission orders, and the equipment was not available until the following day. The resident was discharged back to the hospital before physician orders, diagnosis list, and care plan were initiated. These failures were confirmed through record review, staff interviews, and resident interviews, and were found to have the potential to affect a limited number of residents.
Failure to Report Medication Regimen Irregularities for NPO Residents
Penalty
Summary
The facility failed to ensure that the pharmacist reported medication regimen irregularities to the attending physician, medical director, and director of nursing, and that these reports were acted upon, as required by facility policy. Specifically, for three residents with NPO (nothing by mouth) orders, the pharmacist did not identify or report discrepancies where oral medications were ordered and documented as administered, despite the NPO status. The facility's policy required monthly drug regimen reviews, including review of the medical chart and reporting of any irregularities, but these steps were not followed for the affected residents. For the residents in question, orders and medication administration records showed that oral medications were prescribed and recorded as given during periods when the residents were under NPO orders. In interviews, the pharmacist stated that discrepancies would be reported if found, but no such discrepancies were indicated in the medication regimen reviews for these residents. The DON reported that medications were given via tube and that nursing staff were aware of the NPO status, but the documentation and pharmacist review did not reflect or address the route discrepancies. This failure was identified through record review and staff interviews, affecting three residents out of a facility census of 116.
Inaccurate Medical Records and Medication Administration for NPO Residents
Penalty
Summary
The facility failed to maintain accurate and consistent medical records and physician orders for multiple residents, specifically regarding fall interventions and medication administration routes for residents with NPO (nothing by mouth) orders. For one resident, there was a discrepancy between the care plan and physician orders for fall interventions, with the care plan listing a low bed parameter mattress while the physician orders included 1:1 supervision and floor mats, but no order for a low bed. Additionally, this resident had an active NPO order, yet the Medication Administration Record (MAR) documented the administration of several oral medications over a period of months, despite the NPO status. Two other residents with NPO orders also had MARs indicating the administration of oral medications during their NPO periods. In both cases, the DON reported that medications were given via tube and that nursing staff were aware of the residents' NPO status, but the documentation did not reflect the correct route of administration. These inconsistencies in documentation and failure to accurately follow and record physician orders for both fall interventions and medication administration routes were confirmed by facility leadership during the survey.
Failure to Provide Timely Incontinence Care Resulting in Neglect and Skin Breakdown
Penalty
Summary
The facility failed to protect residents from neglect and verbal abuse, as evidenced by two residents not receiving incontinence care for an extended period. Both residents reported to a nurse aide that they had not received incontinence care since early morning, and care was not provided until after lunch. The assigned nurse aide was observed using her personal phone at the nurses' station and did not communicate the residents' needs to other staff. Witness and resident statements confirmed the neglect, despite the initial facility investigation being unverified. Further review revealed that one resident's spouse found the resident in a soiled and disintegrated brief, with the resident exhibiting redness in the groin area. A nurse was observed cleaning the resident and expressed anger about the situation. The resident's spouse noted that the resident rarely had skin issues prior to admission. An LPN later found the resident without a brief, with a strong urine odor and pieces of the brief on the floor, and had to request housekeeping assistance. Documentation confirmed a new in-house wound described as incontinence-associated dermatitis.
Failure to Revise Care Plan for Fall Interventions
Penalty
Summary
The facility failed to revise the care plan for a resident regarding fall interventions. Observation revealed that the resident was in a low bed with fall mats on the right side and the left side of the bed against the wall, while receiving 1:1 supervision as ordered. Orders were in place for 1:1 supervision and floor mats on the right side of the bed for both day and night shifts, but there were no orders for a low bed with a parameter mattress. The resident's care plan only included a low bed with a parameter mattress as a fall intervention, and did not document the use of floor mats, the bed against the wall, or 1:1 supervision. These discrepancies were confirmed by the DON and a corporate RN.
Medication Left at Bedside Creates Accident Hazard
Penalty
Summary
A deficiency was identified when a tube of Clotrimazole & Betamethasone cream, a medication, was observed at the bedside of a resident. This observation was made during a facility survey, and the medication was found on the resident's nightstand. The presence of medication at the bedside constitutes an accident hazard and indicates a failure to ensure the environment was free from such hazards and that adequate supervision was provided to prevent accidents. The incident was discovered as a random opportunity during the survey, and the medication was subsequently removed after staff were notified.
Failure to Maintain Sanitary Meal Service Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident during meal service. A registered nurse was observed dropping a cup lid onto the dining room floor, picking it up, and placing it on the counter before filling the cup with ice and a drink. The cup and lid were then handed to a nurse aide, who placed the lid onto the cup and served it to a resident. This action occurred without replacing the contaminated lid until prompted by the surveyor. The Director of Nursing acknowledged the failure to maintain a sanitary eating environment, and the registered nurse involved admitted to not realizing the error until after the fact.
Failure to Maintain Cleanliness, Linen Supply, and Environmental Safety
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations during a survey. Floors throughout the facility were found to be cluttered with paper, dust, and dried liquid spills, and trash cans were full. Personal items were left on the floor in some rooms, preventing housekeeping from sweeping. The facility's auto scrubber was not operational, contributing to the unclean conditions. Specific rooms were identified as being in particularly poor condition. Additionally, two ceiling tiles outside the activity room were stained and needed replacement, and a large ceiling trap door to the attic near the nurses' station was left open, allowing hot air to enter the facility after maintenance work. Several beds in one hallway were observed to be unmade due to a shortage of linens, as confirmed by a nurse aide and the administrator. The clean linen closet was found to be empty of fitted sheets, flat sheets, and blankets, and the administrator acknowledged that the laundry was working to address a backlog. These conditions were confirmed by both staff and the administrator during the survey.
Failure to Provide Sufficient Fluids to Maintain Hydration
Penalty
Summary
Surveyors observed that several residents did not have access to fresh water or fluids at their bedside during a walkthrough. Specifically, residents in multiple rooms either had empty water cups, only a small amount of warm water, or no water at all. One resident was seen finishing a meal without any drink provided, and staff confirmed that the resident had no drink with the meal. Another resident requested ice and stated that fresh water or ice had not been provided since the previous night, with her cup remaining empty. Additional residents also reported infrequent water delivery, indicating they often had to wait until meal times for fluids. Staff interviews revealed inconsistencies in the routine for passing water and ice. A nurse aide stated that water and ice are usually passed every shift, with meals, and as needed, but admitted she had not had time to do so on the day of the survey. The administrator and another nurse aide confirmed that residents needed fresh water and/or ice at the time of the observation. These findings demonstrate a failure to consistently offer sufficient fluid intake to maintain proper hydration and health for residents.
Failure to Follow Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
Surveyors observed that a resident did not have heel boots on as ordered by the physician, which are intended to help prevent pressure ulcers. During the observation, a nurse aide was questioned about the absence of the heel boots and stated she was unsure, as she had only recently started working on that hall. The nurse aide then retrieved the heel boots from under the sink and, after confirming with the resident that she wanted them on, placed them on her. It was confirmed by both the nurse aide and the Director of Nursing that the resident was not wearing the heel boots as per the physician's order at the time of the observation.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean, comfortable, and homelike environment for its residents. In one case, a resident's shared bathroom contained three soiled briefs, four articles of clothing, and a brown, dried substance on the floor and commode seat. The resident stated that neither they nor their roommate used the bathroom, attributing the mess to neighboring residents, and described the bathroom as consistently dirty. The Infection Preventionist confirmed the unsanitary condition of the bathroom during the survey. In another room, a resident's floor was found to have spilled cereal and dried fluid spots in the morning, which remained uncleaned throughout the day despite multiple observations. The Regional Resource RN agreed that the dirty floors did not meet standards for a clean, homelike environment. Additionally, another resident's room was observed to have food on the floor with ants present, and this condition persisted throughout the day. The Regional Resource RN again confirmed the lack of cleanliness. In the facility's north hallway, surveyors found trash and debris, including straw and plastic wrappers, scattered along the floor, as well as a sticky, dried puddle near the nurses' station. Both the RN and other staff acknowledged the presence of trash, debris, and the sticky puddle, confirming the ongoing failure to maintain a clean and safe environment.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve food that was palatable and at a safe, appetizing temperature for at least one resident. During observation, a resident was seen picking at their breakfast and reported that the food was cold and that this was a frequent occurrence, particularly at breakfast and dinner. The resident indicated that food carts were left out before being delivered, contributing to the issue. Upon request, food temperatures were measured on a tray ready for delivery and found to be below the facility's standard of at least 120°F, with oatmeal at 112°F, hash-browns at 86.2°F, and biscuits with gravy at 105.5°F. The Culinary Manager confirmed that these temperatures did not meet the required standard at the time of delivery.
Infection Control Lapses in Equipment and Supply Storage
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices within the facility. Two residents with Continuous Positive Airway Pressure (CPAP) machines were found to have their CPAP masks stored improperly on bedside tables, outside of the provided plastic storage bags, during several observations throughout the day. Both residents confirmed that this was their usual practice, and the Regional Resource Registered Nurse acknowledged that the masks should have been stored in the plastic bags as per infection control protocol. Additionally, another resident's catheter bag and tubing were observed lying on the floor next to the bed, a situation confirmed by a Registered Nurse. Furthermore, a clean linen cart was found uncovered in a hallway, which was also confirmed by the Infection Prevention Nurse. These observations indicate lapses in maintaining proper storage and handling of medical equipment and supplies, directly contravening infection control standards.
Resident Dignity Compromised Due to Lack of Privacy and Failure to Knock
Penalty
Summary
A deficiency occurred when a resident was found lying in bed uncovered, with his buttocks exposed and catheter tubing visible, while his door was open and privacy curtain not drawn, leaving him exposed to anyone passing by. The Infection Prevention (IP) Nurse was present in the hallway and confirmed the resident's exposed state. The IP nurse entered the resident's room without knocking and asked if the resident was cold, to which he responded affirmatively and requested assistance to be covered. The IP nurse later acknowledged that she did not knock before entering the room.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor and facilitate resident choice regarding bathing preferences for two residents reviewed for Activities of Daily Living (ADL). One resident, who preferred showers over bed baths, reported only receiving one shower per week despite being scheduled for two. Documentation over a 30-day period showed that this resident received only three showers and seventeen bed baths or sponge baths, contrary to her stated preference and care plan. The administrator confirmed that the resident was not receiving ADL care according to her preferences. Another resident, with a history of CVA, left hemiplegia, anoxic brain injury, craniotomy, spinal stenosis, myelopathy, confusion, impaired mobility, and weakness, also expressed dissatisfaction with the bathing process and reported not consistently receiving scheduled showers. Review of records indicated that out of seventeen opportunities, the resident received only four showers, with four documented refusals and nine instances where bed baths were given without any refusal noted. The administrator confirmed that this resident's preference for showers, as documented in the care plan, was not being met.
Failure to Limit PRN Psychotropic Medication and Attempt Non-Pharmacological Interventions
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications and did not ensure a resident was free from chemical restraints. Specifically, a resident was prescribed PRN Ativan orders that extended beyond the 14-day limit without documented physician or practitioner review and rationale for continuation. The resident received multiple PRN Ativan orders, each lasting longer than 14 days, and there was no evidence that these orders were appropriately reviewed or justified as required. Additionally, the facility did not attempt or document non-pharmacological interventions prior to administering PRN Ativan on several occasions, despite the resident's care plan indicating that such interventions should be attempted for mood and behavior concerns. The Medication Administration Record did not track these interventions, and progress notes only documented the administration of medication in response to symptoms such as anxiety or psychosis, without reference to non-pharmacological measures. The DON confirmed the lack of documentation and acknowledged that non-pharmacological interventions were not attempted or recorded as required.
Failure to Implement Care Plans for Medication and Activities
Penalty
Summary
The facility failed to implement care plan interventions for two residents, resulting in deficiencies related to medication administration and activity engagement. For one resident with a history of anxiety, bipolar disorder, psychosis, and recent admission from a long-term psychiatric hospital, the care plan required staff to attempt non-pharmacological interventions before administering PRN Ativan. However, on multiple occasions, the medication was given without evidence that these interventions were attempted, as confirmed by both documentation review and the Director of Nursing. Progress notes and the Medication Administration Record did not reflect any non-pharmacological measures being used prior to medication administration on the specified dates. Another resident, who is highly visually impaired and at risk for limited engagement, had a care plan that included specific interventions such as one-to-one visits, reading the daily chronicle, and assistance with adaptive equipment for activities. Review of activity participation records over several months showed that the resident participated in group activities only six times and was not regularly receiving the individualized interventions outlined in the care plan. The Activity Director confirmed that these interventions were not consistently provided and acknowledged missing the decline in the resident's participation. Both cases demonstrate that the facility did not follow the individualized care plans developed to meet the residents' needs. The lack of implementation of non-pharmacological interventions before administering PRN medication and the failure to provide planned activity adaptations and engagement opportunities were confirmed through record reviews and staff interviews. These actions and omissions led directly to the cited deficiencies.
Failure to Provide Activities Program Meeting Resident Needs
Penalty
Summary
The facility failed to provide a program of activities that met the needs and interests of a resident with highly impaired vision. Multiple observations over several days showed the resident lying in bed, often in a dark room, with no television or radio on and no other forms of stimulation. The resident was observed talking to herself and holding a cup, with no evidence of engagement in activities. The resident's care plan included specific interventions such as offering room visits for socialization, reading the daily chronicle, providing music, and using adaptive techniques to enable participation in activities. However, these interventions were not consistently implemented. A review of the resident's activity participation records over several months revealed minimal participation in group activities and a lack of regular one-to-one visits or assistance with adaptive activities as outlined in the care plan. The Activity Director confirmed that the resident was not on a one-to-one visit schedule and acknowledged a decline in the resident's participation, which had gone unnoticed. The resident's Minimum Data Set indicated that participation in activities and social engagement were very important to her, yet these preferences were not being met.
Failure to Follow Physician Orders and Timely Medication Administration
Penalty
Summary
Surveyors identified that the facility failed to follow physician orders and protocols for multiple residents. For one resident, an elevated ammonia level was identified, and the physician ordered an increase in Lactulose and a repeat ammonia level in one week. However, the repeat ammonia level was not completed as ordered. Another resident experienced a documented hypoglycemic event with a blood glucose level of 47, but the hypoglycemia protocol, which included specific interventions and monitoring, was not followed as per the physician's orders. The resident's care plan included instructions to follow the hypoglycemia protocol, but documentation did not reflect that these steps were taken. Additionally, a third resident reported not receiving medications on time, and record review confirmed that several medications were either not administered or were given outside the facility's policy window for timely administration. These included oral medications for saliva balance, pancrelipase, cetirizine, prednisone, and insulin, with some doses missed or significantly delayed. The facility administrator and a regional resource RN confirmed these findings, acknowledging that physician orders and protocols were not followed as required.
Failure to Provide Correct Prescription Glasses
Penalty
Summary
The facility failed to ensure that a resident received the correct prescription reading glasses as ordered by an Ophthalmologist. The resident reported that, despite an eye examination and prescription for glasses provided six months prior, she had not received the prescribed glasses and was instead given a pair that did not allow her to see well. Record review confirmed the resident's last Ophthalmologist appointment and the specific prescription for reading glasses. Staff interviews further verified that the resident was not provided with the correct prescription glasses as ordered by the Ophthalmologist.
Mattress Left in Hallway Creates Accident Hazard
Penalty
Summary
A mattress was found lying on the floor in the north hallway, a resident area, in front of the mechanical room and the entrance to the kitchen/service hall at approximately 7:30 AM. This observation was made during a survey and was acknowledged by both a nurse aide and a registered nurse, who confirmed that the mattress should not have been left there. Both staff members recognized that the mattress constituted a hazard and that a resident could have fallen over it. The facility census at the time was 117.
Failure to Provide Adequate Hydration
Penalty
Summary
Surveyors found that the facility failed to provide sufficient fluid intake to maintain proper hydration and health for two residents. One resident reported difficulty obtaining water, and repeated observations throughout the day revealed that the disposable cup at the bedside remained empty. Another resident stated that staff would not always provide water and sometimes told the resident it was unnecessary; observations also showed the bedside cup was empty at multiple times during the day. The Administrator confirmed that both residents had not received proper hydration on the day in question.
Failure to Provide Routine Dental Services to Medicaid Resident
Penalty
Summary
The facility failed to provide routine dental services to a Medicaid-funded resident who was identified as being at risk for oral health problems due to poor dentition. The resident reported having only three teeth, with the upper tooth causing occasional pain and difficulty chewing. Despite a care plan noting the presence of obvious caries and the need for dental consults or referrals, there was no evidence in the medical record that any dental consults had been obtained since the resident's admission. The resident's MDS assessment also indicated the presence of obvious or likely cavities or broken natural teeth. Interviews and record reviews revealed that the resident was scheduled to be seen by the facility's dental provider but was not seen as planned. After missing the scheduled appointment, the resident was not placed back on the dental provider's list for subsequent visits, despite the provider visiting the facility every three months. The facility's policy requires annual oral inspections and routine dental care, but these services were not provided to the resident as required.
Incomplete and Improperly Authenticated Neurological Assessments After Resident Falls
Penalty
Summary
A review of the electronic health record revealed that a resident who had experienced seven falls during their stay did not have properly completed post-fall neurological assessments. Specifically, one assessment scanned into the resident's health record was missing correct dates and lacked the nurse's signature in eight instances. For a fall that occurred at 6:00 PM, the neurological assessment form was missing all four signature slots for the 30-minute checks and all four signature slots for the hourly checks. Additionally, the hourly checks that occurred after midnight were not dated to reflect the correct day the assessments were performed. The administrator confirmed that the neurological assessments were not signed or dated at the required times. The DON also verified that the original form was not completed accurately. These findings indicate that the facility failed to maintain medical records in accordance with accepted professional standards, specifically regarding the documentation and authentication of post-fall neurological assessments for the resident.
Failure to Provide Accessible Over-Bed Light Controls
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's needs by not ensuring that the over-bed light could be turned on and off by the resident at will. During an interview and observation, the resident reported being unable to reach the light switch string, which was found to be only about an inch long and out of reach. The Director of Nursing confirmed during an observation that the light string was not accessible to the resident. This deficiency was identified through resident and staff interviews and direct observation.
Failure to Revise Care Plans for Fall Prevention and Dietary Restrictions
Penalty
Summary
The facility failed to revise care plans to reflect current interventions for fall prevention and dietary restrictions for four residents. For three residents, the care plans did not include updated fall prevention measures that had been implemented, such as ensuring the call light was within reach, adding non-skid strips to the bed, using a dumped wheelchair, and providing non-skid footwear. These omissions were identified during record reviews, which showed that the care plans were not updated to include these specific interventions. Additionally, for one resident with dietary restrictions prohibiting cold foods and drinks, the care plan did not accurately reflect the resident's inability to tolerate very cold or hot beverages or foods. The resident's diet order specified no cold food or drinks, but the care plan did not address the restriction on hot items, and the resident continued to receive soups, coffee, tea, and hot chocolate. These findings were confirmed by facility staff during interviews.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a nonverbal resident from physical abuse by another resident. The incident involved a resident with a history of physical aggression, psychiatric disorders, and medication noncompliance, who was witnessed hitting a nonverbal resident multiple times in the face. The assaulted resident sustained visible swelling and bruising on the left side of the face, was grimacing, and could not be consoled. The resident was sent to the emergency department for evaluation, where no acute injuries were found, and later returned to the facility at baseline mood and interaction. Prior to this incident, the aggressive resident had a documented history of behavioral issues, including a previous episode of physical aggression toward another resident. The care plan for this resident identified multiple risk factors such as cognitive deficits, psychiatric diagnoses, poor impulse control, and a pattern of challenging behaviors. Interventions included frequent monitoring, behavioral assessments, and attempts to manage the resident’s environment and triggers. Despite these measures, the resident continued to refuse medication and exhibited escalating behaviors. The facility's records indicate that staff were aware of the resident’s behavioral risks and had implemented interventions such as visual checks and psychiatric consultations. However, these interventions did not prevent the physical abuse of the nonverbal resident. The facility was unable to provide further information regarding the incident beyond the immediate response and care provided to both residents involved.
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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