Raleigh Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Daniels, West Virginia.
- Location
- 1631 Ritter Drive, Daniels, West Virginia 25832
- CMS Provider Number
- 515088
- Inspections on file
- 25
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Raleigh Center during CMS and state inspections, most recent first.
A medicine cart was left unlocked and unattended by an LPN during a med pass, creating an accident hazard. The LPN acknowledged the oversight upon returning to the cart, and the administrator confirmed that the cart should have been locked when not in direct view. This situation had the potential to impact multiple residents in the facility.
Surveyors identified deficiencies in food storage and sanitation, including food items stored on the floor, serving pans and bowls stacked while still wet, and an unclean oven with visible debris and grease. Dietary staff confirmed these conditions during interviews.
The facility failed to maintain a homelike environment by not removing meal trays after service and storing trash bags on hand towel racks in residents' rooms. The ADON and Administrator acknowledged the oversight regarding meal trays, while an LPN confirmed the inappropriate storage of trash bags, which were kept for staff use.
A facility failed to protect residents from abuse and neglect, as a NA neglected duties by ignoring call lights and using her phone, leading to an RN covering her responsibilities. A resident waited over an hour for food due to communication failures. Another resident with a history of aggression was involved in altercations, but the facility did not implement effective interventions or report incidents, as acknowledged by the DON.
The facility was found to have deficiencies in safety and medication management. A resident struggled to maneuver his wheelchair over fall mats, and oxygen tanks were improperly stored without signage. Additionally, medication carts were left unlocked with medications unsecured, and a nurse was unable to identify a resident's medication. These issues were acknowledged by staff and had the potential to affect multiple residents.
The facility failed to provide nighttime snacks to residents as required. Snacks were left undelivered at the nurses' station, affecting multiple residents. Staff confirmed they did not distribute the snacks, and residents reported not receiving them. The facility's policy requires snacks to be offered within 15 minutes of delivery, but this was not followed.
The facility failed to maintain sanitary food storage and handling practices. An expired jar of apple sauce was found in use, and the ADON was observed assisting a resident without sanitizing hands before handling a clean tray. Additionally, a refused meal tray was improperly returned to the food delivery cart, risking cross-contamination.
A resident reported delays in call light response and restrictions on mobility after using the bedpan, feeling punished for needing assistance. Despite her care plan emphasizing physical activity, staff reportedly told her it was against the rules to get back up after being placed in bed. The DON was unaware of these issues.
A resident's call light was improperly positioned, making it inaccessible due to her inability to use her left hand. An LPN acknowledged the issue and repositioned the call light. The DON and Nurse Educator confirmed the resident's dependency with upper extremities and lack of documentation or care planning for her condition.
A facility failed to implement its Abuse Prohibition policy, leading to multiple incidents involving a resident with aggressive behavior. Despite documented aggressive actions towards other residents, the facility did not take adequate steps to prevent further incidents or provide sufficient supervision. The facility also failed to report allegations of abuse within the required timeframe, contributing to the deficiency identified by surveyors.
A resident with a history of aggressive behavior was involved in multiple altercations with other residents, including pulling hair and hitting. Despite these incidents, the facility failed to report and investigate the allegations of abuse as required by their policy. The DON acknowledged the lack of intervention and documentation, and the facility's social worker confirmed no investigation was conducted for one incident.
A facility failed to investigate an alleged violation involving a resident's fracture, as statements from all relevant staff, including an NA involved in the resident's care, were not obtained. The resident's care plan required two-person assistance for bed mobility and toileting, but documentation showed only one-person assistance was provided on multiple occasions. The facility did not review documentation that could have identified the risk for accidents.
A facility failed to accurately complete an MDS for a resident discharged home. The nursing notes and discharge plan indicated a home discharge, but the MDS incorrectly recorded a discharge to a short-term hospital. The DON confirmed the error during an interview.
A facility failed to create an individualized care plan for a resident with depression, despite having a physician's order for Escitalopram. The care plan lacked specific measures to address the resident's depression, a deficiency confirmed by the DON during an interview.
The facility failed to follow physician orders for a resident who was observed without a required protective helmet while out of bed, despite having a history of brain surgery. Additionally, another resident with bipolar disorder reported receiving medications late, which was confirmed by the DON. These deficiencies highlight lapses in adhering to care plans and medication schedules.
A facility failed to timely act on a Medication Regimen Review (MRR) for a high-risk medication for a resident with multiple diagnoses, including anxiety and dementia. The MRR recommended a review of Buspar dosage, but the facility did not address it within the required 30 days, delaying action until a psychiatrist's visit months later. This oversight was acknowledged by the facility's Infection Preventionist, indicating a deficiency in medication management.
Two residents were served incorrect diets when bologna sandwiches were provided instead of the required Peanut Butter and Jelly sandwiches. The Dietary District Manager confirmed that both residents needed ground meat, which was not provided. Meal tickets verified the dietary errors.
The facility failed to properly dispose of garbage and refuse, as observed during a tour. The dumpster was found open with debris, including food particles, trash, gloves, and masks scattered around it. A housekeeper and the DON acknowledged the condition of the dumpster and the surrounding area.
The facility failed to maintain accurate medical records for two residents. One resident's blood pressure was incorrectly documented as being taken from a prohibited arm, despite her refusal and medical orders against it. Another resident was receiving medication for depression without a corresponding diagnosis in the records. The DON acknowledged these documentation errors.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when a medicine cart was left unlocked and unattended during a medication pass. An LPN was observed preparing medication at the cart and then entered a resident's room, leaving the cart unsecured. Upon returning, the LPN acknowledged that the cart had been left unlocked. The facility administrator confirmed that the medication cart should have been locked when not in the nurse's direct line of sight. This incident presented an accident hazard and had the potential to affect more than a limited number of residents in the facility, which had a census of 65 at the time.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and serving practices. Specifically, a case of oats and a case of grits were found sitting directly on the floor in the dry stock room, both dated for recent delivery. Additionally, five trays with blue serving bowls were found near the food plating area while still wet, and further inspection revealed that large, medium, and small pans used for serving food were also stacked while wet, with water running off the pans onto the floor. These observations were confirmed by dietary staff present at the time. Further inspection of the facility's cook range and ovens revealed that the bottom right oven contained crumbs, burnt substances, and a dried white/yellow substance resembling old grease drippings. Dietary staff interviewed stated that the bottom ovens were not in use and were unsure how they became soiled. These findings indicate that food was not being stored, prepared, or served in accordance with professional standards, as required.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for its residents, as observed during a meal tray service and a tour of Unit B. During the meal service, trays were placed on tables for residents but were not removed afterward, contrary to the facility's policy. This was acknowledged by both the Assistant Director of Nursing and the Administrator, who confirmed that the trays should have been removed according to the policy titled NSG270 Meal Service. Additionally, during a tour of Unit B, it was observed that trash bags were stored on the hand towel racks in residents' rooms, alongside clean towels and washcloths. This practice was confirmed by an LPN, who stated that the staff stored the trash bags there for personal use, acknowledging that it did not create a homelike environment for the residents. These deficiencies were noted to have the potential to affect a limited number of residents within the facility, which had a census of 63 at the time.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by several incidents involving staff and residents. A Nurse Aide (NA) was observed neglecting her duties by ignoring call lights and using her cell phone during her shift. This neglect resulted in a Registered Nurse (RN) having to leave her medication cart to answer a call light in the NA's assigned area. The NA was also observed taking an unauthorized smoke break, further neglecting her responsibilities. Resident #2 experienced neglect when she requested food after missing lunch, and her request was not communicated to the kitchen staff in a timely manner. Despite the Licensed Practical Nurse (LPN) acknowledging the request, the Dietary Manager confirmed that no request had been made. As a result, Resident #2 waited over an hour and twenty minutes before receiving her meal, highlighting a breakdown in communication and care delivery. Resident #16, who has a history of aggressive behavior and multiple psychiatric diagnoses, was involved in several altercations with other residents. Despite documented incidents of aggression, including hitting and pulling hair, the facility failed to implement effective interventions or report the incidents as required by their abuse prohibition policy. The Director of Nursing (DON) acknowledged the lack of documentation and reporting for these incidents, indicating a failure to follow established procedures to protect residents from abuse.
Deficiencies in Safety and Medication Management
Penalty
Summary
The facility was found to have several deficiencies related to accident hazards and inadequate supervision. During a tour, a resident was observed struggling to maneuver his wheelchair over fall mats placed around his bed, which impeded his ability to safely access his side of the room. The Licensed Practical Nurse (LPN) acknowledged that the mats should be removed when residents are out of bed, indicating a lapse in ensuring a hazard-free environment. Additionally, oxygen tanks were found unattended in a resident sitting area without proper signage, posing a potential safety risk. The Registered Nurse (RN) confirmed that the oxygen tanks should not have been stored there and removed them upon discovery. Further deficiencies were noted in the storage of medications. During facility tours, medication carts were found unlocked with keys in the locks, and medications were left unsecured on top of the carts. In one instance, a nurse was unable to identify the resident to whom a medication belonged, highlighting a lack of proper medication management. The Director of Nursing acknowledged that the medication carts should have been locked and medications securely stored, as per the facility's policy. These lapses in medication storage and environmental safety had the potential to affect more than a limited number of residents in the facility.
Failure to Provide Nighttime Snacks to Residents
Penalty
Summary
The facility failed to provide snacks to residents who wished to receive them at night, as observed during a survey. Multiple residents, including Resident #24, #28, #33, #51, #52, #22, and #58, were affected by this deficiency. The snacks, which were supposed to be delivered during the third shift, were found undelivered and left at the nurses' station. Interviews with the District Dietary Manager and the Dietary Manager confirmed that the snacks were not passed to the residents as required. The Dietary Manager noted that the last dietary employee leaves at 7:00 PM, and the snacks are left at the nurses' station, where they often remain untouched until the next day. Nurse Aides #15 and #33 confirmed that they had not offered the snacks to residents during their shifts. They admitted that the snacks were left at the nurses' station and were not distributed to the residents. Resident #28 expressed disappointment at not receiving the snack, stating that they would have liked to have it but were unaware of its availability. Similarly, Resident #52 reported that they rarely received snacks before bed, estimating that it happened less than once every two weeks. The facility's policy for meal and snacks requires that evening snacks be offered to every resident, with snacks being passed within 15 minutes of delivery to the unit. However, the Director of Nursing acknowledged that the facility had not been following these procedures. Resident Council members, including Residents #22 and #58, also reported that snacks were not consistently offered at bedtime, with staff often leaving them at the nurses' station instead of distributing them to residents.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a sanitary manner, as observed during a kitchen tour and dining observations. During a kitchen tour, a jar of apple sauce with a discard date of 7/19/24 was found in the reach-in refrigerator and was still in use. This was acknowledged by a staff member and later by the Dietary Manager during an interview. This oversight indicates a lapse in monitoring and adhering to food safety protocols regarding the storage and use of expired food items. Additionally, during dining observations, the Assistant Director of Nursing (ADON) was seen assisting a resident with eating and then handling a clean tray without sanitizing her hands, which poses a risk of cross-contamination. Furthermore, the ADON placed a refused meal tray back into the food delivery cart with other trays that had not yet been served, which she acknowledged could lead to cross-contamination. The Administrator confirmed that the tray should not have been returned to the cart, indicating a breach in proper food handling procedures.
Resident Dignity Compromised by Delayed Response and Mobility Restrictions
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity, as evidenced by the experiences of a resident who reported delays in response to her call light and restrictions on her mobility after using the bedpan. The resident, who is blind and requires a lift for transfers, reported that staff often took up to 20 minutes to respond to her call light. She also stated that after using the bedpan, she was not allowed to get out of bed for the rest of the day, which made her feel as though she was being punished for needing to use the bathroom. This was corroborated by her private caregiver, who reported hearing a nurse aide suggest that the resident use her brief instead of being transferred back to bed. The resident's care plan indicated that she was at risk for falls and required assistance with transfers using a full-body sling. The care plan also emphasized the importance of maximizing physical activity to enhance muscle tone and mobility. Despite this, the resident reported being told that it was against the rules to get back up after being placed in bed. The Director of Nursing was unaware of these issues and had not received any complaints from the resident prior to the surveyor's report.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was positioned in a manner that allowed her to use it effectively, which was identified during a long-term care survey. The resident, who was unable to use her left hand, was found with her call light clipped to the left side of her bed, making it inaccessible. This issue was observed when a Licensed Practical Nurse (LPN) entered the room and acknowledged the call light was on the non-dominant side, subsequently moving it to the resident's right side. The Director of Nursing (DON) and Nurse Educator later confirmed that the resident's minimum data set (MDS) indicated dependency with upper extremities, and there was no documentation from a physician addressing the resident's inability to use her left hand. Despite the resident working with physical therapy to strengthen her left hand, the deficiency was noted due to the lack of care planning and diagnosis for her condition.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its Abuse Prohibition policy, resulting in multiple incidents involving Resident #16, who has a history of aggressive behavior. Resident #16, diagnosed with various mental health disorders including schizoaffective disorder and dementia, exhibited aggressive behavior towards other residents, including pulling hair and hitting. Despite these behaviors being documented in progress notes and the electronic medication administration record, the facility did not take adequate steps to prevent further incidents or provide sufficient supervision. On several occasions, Resident #16 was involved in altercations with other residents, including an incident where she hit her roommate, Resident #24, during a surveyor's observation. The facility's policy required that any patient who threatened or attacked another be removed from the situation and that an investigation be conducted. However, the Director of Nursing (DON) admitted that no interventions, such as room changes, were implemented due to the family's wishes, and there was a lack of documentation and investigation for some incidents. The facility also failed to report allegations of abuse within the required two-hour timeframe, as mandated by their policy and state regulations. The DON acknowledged that the facility did not follow the Abuse Prohibition policy, and the Social Worker confirmed that no investigation or report was made for a specific incident. This lack of adherence to policy and failure to document and report incidents contributed to the deficiency identified by the surveyors.
Failure to Report and Investigate Resident Aggression
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #16, who has a history of aggressive behavior towards staff and other residents. Resident #16 has multiple diagnoses, including schizoaffective disorder, bipolar type, and vascular dementia with behavioral disturbance, and is on several medications. The resident's care plan includes interventions for managing cognitive and mood symptoms, but there were several documented incidents of aggressive behavior, including pulling another resident's hair and hitting a roommate. Despite these incidents, the facility did not follow its policy on abuse prohibition, which requires reporting allegations of abuse within two hours. The Director of Nursing (DON) acknowledged that no intervention was put in place to prevent further altercations between Resident #16 and other residents, citing the family's wishes not to separate Resident #16 from her roommate. The DON also admitted that there was no investigation or documentation for certain incidents, and the facility's social worker confirmed that an investigation was not conducted for one of the incidents. The surveyor observed an altercation where Resident #16 hit her roommate, Resident #24, during a tray pass for lunch. Nurse aides intervened to separate the residents, but the facility's failure to report and investigate previous incidents contributed to the ongoing risk of harm. The DON was unable to provide documentation for several incidents and acknowledged that the facility's abuse prohibition policy was not followed.
Failure to Investigate Alleged Violation and Provide Correct Level of Care
Penalty
Summary
The facility failed to thoroughly investigate an alleged violation involving a resident who sustained a moderately displaced impaction fracture of the distal femur metaphysis. The investigation did not include statements from all relevant staff members, particularly Nursing Assistant (NA) #63, who was involved in the resident's care during the time leading up to the incident. The facility was unable to determine the origin of the injury, and the investigation did not adequately review the level of care provided to the resident, which was documented as requiring extensive assistance from two persons for bed mobility and toileting. The facility's documentation revealed that the resident received only one-person assistance for these tasks on multiple occasions, contrary to the care plan requirements. This discrepancy was not identified or addressed during the investigation. The Director of Nursing (DON), Nurse Practice Educator (NPE) #34, and Social Worker (SW) #61 acknowledged that they did not review the facility's Documentation Survey Report for assisted daily living tasks, which could have highlighted the risk for accidents. NA #63, who was involved in providing incorrect assistance, was not interviewed as part of the investigation, and had not returned to the facility since the incident.
Inaccurate MDS Completion for Discharged Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) for a resident who was discharged home. During a medical record review, it was found that the nursing notes and discharge plan documentation indicated the resident was discharged home, with their belongings packed and medications discussed. However, the MDS inaccurately recorded that the resident was discharged to a short-term general hospital. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged the incorrect coding on the MDS.
Failure to Develop Comprehensive Care Plan for Depression
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan for a resident diagnosed with depression. During a medical record review, it was found that the resident had a physician's order for Escitalopram Oxalate Tablet 20 MG to be administered for depression. However, the resident's care plan did not include a specific plan addressing this diagnosis. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the comprehensive care plan for depression had not been developed for the resident.
Failure to Follow Physician Orders and Medication Administration Times
Penalty
Summary
The facility failed to provide care according to physician orders for Resident #15, who had multiple diagnoses including hemiplegia, epilepsy, cerebral palsy, and a history of traumatic brain injury. The resident had a physician's order to wear a protective helmet when out of bed to prevent injury due to a previous brain surgery. However, observations on multiple occasions revealed that the resident was out of bed in a geri-chair without the helmet. An LPN acknowledged the oversight, mistakenly believing the order had been discontinued, but confirmed it was still active. Additionally, the facility did not administer medications on time for Resident #25, who has a diagnosis of bipolar disorder and reported difficulty sleeping if evening medications are delayed. The resident's medications, including Tamsulosin and Depakote, were documented as being administered several hours late on specific dates. The Director of Nursing confirmed the late administration of these medications, acknowledging the failure to adhere to the scheduled times.
Failure to Timely Act on Medication Regimen Review
Penalty
Summary
The facility failed to timely act upon a Medication Regimen Review (MRR) for a high-risk medication for one of the residents reviewed during the Long-Term Care Survey Process. The resident, identified as Resident #16, had multiple diagnoses including anxiety disorder, insomnia, major depressive disorder, schizoaffective disorder, psychotic disorder with hallucinations, unspecified dementia, Alzheimer's disease, and vascular dementia with behavioral disturbance. The resident was receiving several medications, including Clonazepam, Cymbalta, Nuplaid, and Remeron. A recommendation from an MRR dated January 17, 2024, suggested a review of the current dose of Buspar for a gradual dose reduction, as per CMS regulations. The facility's policy required acting upon pharmacy recommendations within 30 calendar days. However, the recommendation from the MRR was not addressed until a psychiatrist's visit on May 17, 2024, which was well beyond the 30-day requirement. During interviews, the facility's Infection Preventionist acknowledged the delay, indicating that the facility had not acted upon the recommendation in a timely manner, contrary to their policy. This oversight was identified during a record review and staff interview, highlighting a deficiency in the facility's medication management process.
Incorrect Diets Served to Two Residents
Penalty
Summary
The facility failed to provide the correct diet to two residents, identified as Resident #24 and Resident #28, as observed during a tour of the nourishment room. At approximately 10:15 AM, two bologna sandwiches were found labeled for these residents, although the labels indicated they should have received Peanut Butter and Jelly sandwiches. The dietary needs for both residents required ground meat, as confirmed by the Dietary District Manager (DDM) during an interview. The DDM verified that neither resident should have received a bologna sandwich unless the meat was chopped. Upon reviewing the meal tickets, it was confirmed that the wrong diets were served, with Resident #24 requiring a Regular/Liberalized-Advanced diet with ground meat and Resident #28 requiring a Consistent Carbohydrate-Advanced diet with ground meat.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a tour at approximately 10:00 AM on August 25, 2024. The dumpster was found with its lid and door open, surrounded by debris including food particles and trash scattered on the ground. Additionally, gloves and masks were observed lying around the dumpster area. Housekeeper #88 acknowledged the condition of the dumpster and the surrounding area, and the Director of Nursing (DON) also confirmed the state of the dumpster upon arrival at the facility.
Deficiencies in Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to accurately maintain medical records for two residents, leading to deficiencies in documentation. For one resident, the facility incorrectly documented blood pressure readings taken from the left arm, despite medical orders prohibiting this due to the presence of a fistula. The resident, who is cognitively intact with a BIMS score of 15, confirmed that she does not allow blood pressure measurements on her left arm, indicating that the documentation errors were not due to actual practice but rather incorrect record-keeping. The Director of Nursing acknowledged these errors and stated that the facility was auditing the notes and documentation. For another resident, the facility's medical records showed a discrepancy between the physician's orders and the documented diagnoses. The resident was receiving medication for depression, yet there was no corresponding diagnosis of depression listed in the medical records. The Director of Nursing confirmed this inconsistency and agreed that the diagnosis was missing from the records, indicating a lapse in ensuring accurate and complete medical documentation.
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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