River Oaks Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clarksburg, West Virginia.
- Location
- 100 Parkway Drive, Clarksburg, West Virginia 26301
- CMS Provider Number
- 515120
- Inspections on file
- 23
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at River Oaks Healthcare Center during CMS and state inspections, most recent first.
Surveyors observed that one of two resident shower rooms on a resident hall had a damaged wall area covered with black tape and stained, discolored tile grout in the shower stall, indicating the environment was not maintained in a safe, clean, comfortable, and homelike condition. These environmental concerns were confirmed by the Director of Plant Maintenance and acknowledged by the Administrator.
Surveyors observed Sani wipes left on vending machines in a day room, multiple hazardous items including equipment and a broken picture frame in an open Internet cafe/storage area, and exposed wiring outside a resident room. Staff interviews confirmed these areas were accessible to residents and that hazardous conditions had been present for some time.
Surveyors found open soda cans on a PPE cart, exposed lift pads on a clean linen cart, and unclear PPE/EBP precaution signage that did not specify which resident required precautions. Staff interviews confirmed improper storage practices and confusion about infection control signage.
Staff failed to consistently remove soiled incontinence briefs from resident rooms after care, as reported by two cognitively intact residents and confirmed by multiple staff interviews. The ongoing presence of soiled briefs led to unpleasant odors and indicated a lapse in adherence to facility protocols for maintaining a clean environment.
Surveyors observed that the dumpster area was polluted with garbage and used medical supplies, and this was confirmed by the Administrator. This improper storage of refuse had the potential to affect all residents in the facility.
A medication administration error occurred when an RN failed to give prescribed medications to multiple residents over several night shifts, and the facility did not complete required staff re-education or medication cart audits as part of its correction plan. The missed medications included treatments for chronic conditions such as diabetes, hypertension, and depression.
The facility did not maintain an effective pest control program, resulting in a widespread gnat infestation observed in resident rooms and common areas. Staff confirmed the issue, and an exterminator stated he had not been called to address gnats prior to the survey. A resident reported having to kill gnats herself and experienced delayed garbage removal, with no follow-up from administration after reporting her concerns.
Surveyors found multiple failures in food safety and sanitation, including unlabeled and spoiled food in the refrigerator, open food items in the freezer, dented cans in dry storage, and unclean kitchen equipment and surfaces. The dishwasher was used despite not reaching the required rinse temperature, and ice machine drains lacked the necessary air gap due to broken brackets.
The facility failed to maintain an effective infection prevention and control program, as evidenced by a resident with cognitive impairment being allowed to play with feces in the dining room without staff intervention, overflowing trash and soiled linen containers left unattended, and wound care provided to a resident under Enhanced Barrier Precautions without proper PPE or signage.
Surveyors observed a black substance and debris around PTAC units in dining rooms and on ceiling vents throughout the facility. The Maintenance Director confirmed these findings, which had the potential to impact all residents, staff, and visitors.
Surveyors found that several residents were prescribed medications without appropriate diagnoses or indications, including drugs for dementia, depression, and seizures, as well as an antibiotic to which a resident was allergic. The DON confirmed the lack of supporting documentation or diagnoses, and the consultant pharmacist missed a medication irregularity due to timing of the order.
The facility did not follow planned menus or provide required food items due to frequent shortages, resulting in a resident repeatedly not receiving items such as milk, bread, and specific entrees as listed on meal tickets. Staff confirmed that menu changes were not communicated to residents and that food substitutions were made without notice.
Multiple residents experienced undignified dining conditions, including witnessing a cognitively impaired resident play with a soiled brief in the dining room without staff intervention, being served meals late, and being required to eat off serving trays. Additionally, residents reported long wait times for call light responses, with one resident waiting nearly 20 minutes for assistance during an episode of diarrhea. Staff interviews confirmed these practices and delays.
The facility did not document or respond to concerns raised by residents during council meetings, including repeated requests for menu changes. Staff failed to record these grievances in official logs or meeting minutes, and the Administrator was unaware of the ongoing issues, despite residents being cognitively intact and able to recall their requests.
Diagnosis sheets and mini nutritional assessments containing confidential information were left in an unsecured wall file holder outside the medical records office, making them accessible to anyone passing by. The Medical Records Coordinator confirmed that these documents, printed by an MDS RN, were not properly secured and included private resident information.
Several residents were observed to be cold in the dining room, with some wearing extra layers or using blankets. The ambient temperature was measured at 65.5°F, below the required minimum of 71°F. The Maintenance Director confirmed that staff sometimes turn on the air conditioner, leading to the uncomfortable environment.
Multiple cognitively intact residents voiced concerns about menu options, room cleanliness, food quality, and missing personal property, but their verbal grievances were not documented, investigated, or resolved by facility staff. The Administrator and housekeeping staff failed to follow grievance procedures, resulting in unresolved issues and lack of communication with the residents.
Several residents' care plans were not updated to reflect their preferences for showers, history of refusals, or current wound care needs. For example, residents who preferred showers did not have this preference or their refusals documented in their care plans, and residents with pressure ulcers did not have individualized interventions for wound care or turning and repositioning included in their plans, despite staff and DON confirmation of these needs.
Multiple residents did not receive prescribed medications over several night shifts, with staff documenting administration that did not occur. A resident experienced significant unaddressed weight loss without required re-weighs, and another had unclear documentation regarding enteral feeding flushes. These deficiencies reflect failures in medication administration, monitoring, and adherence to physician orders.
Surveyors found that medication and treatment carts were left unlocked and unattended in multiple hallways, with LPNs confirming responsibility for the carts. These actions resulted in accident hazards in areas accessible to residents, as confirmed by facility leadership.
The facility did not provide enough direct care staff on multiple occasions, falling below its own assessed staffing requirements. As a result, dependent residents did not receive showers, one resident was not showered at their preferred time, a resident with a Stage III pressure ulcer was not turned and repositioned, and another experienced significant weight loss without interventions. These deficiencies were confirmed by staffing records and acknowledged by the DON.
Surveyors found that the facility did not ensure physician responses to pharmacist recommendations for two residents, including failure to address duplicate medication orders and lack of rationale for administering a medication to a resident with a documented allergy. No physician acknowledgment or rationale was documented in the medical records.
A resident experienced a significant weight loss of 10.3% in one month without any dietary assessment or intervention, despite being on a regular diet and consuming 51-100% of meals. No supplements or additional nutrition were ordered, and the DON confirmed that no dietary assessment was completed after the weight loss was identified.
A resident experienced blood in their catheter bag, which was reported by an LPN to both the NP and MD, but neither responded to the message. The resident was not evaluated by a provider until two days later, when they were found to be acutely hypoxic with Cheyne-Stokes respiration and cyanosis, and subsequently stopped breathing.
A resident with a stage III pressure ulcer, who is immobile and fully dependent on staff, was not consistently turned and repositioned as required by standard nursing practice. Despite having wound care orders, there were no documented interventions for regular turning, and record review showed the resident was repositioned far less frequently than recommended. Staff interviews and documentation confirmed the lack of consistent implementation of this essential preventive measure.
Two residents who required assistance with activities of daily living did not receive scheduled showers as ordered, with one resident missing three out of eight showers and another missing six out of eight, resulting in extended periods without proper hygiene. Both residents expressed a preference for showers and there was no documentation of refusals for one resident, while the other had only two refusals documented. The DON confirmed these findings.
A resident's PASARR documentation did not include all pre-admission diagnoses, as the form omitted the resident's Epilepsy diagnosis and only listed major depression. This omission was confirmed by the Director of Social Services during staff interview.
The facility did not consistently follow or update care plans for three residents, including missing behavior monitoring for a resident with behavioral issues, failing to document a history of physical aggression for another, and not providing specific interventions for a resident with legal blindness. These deficiencies were confirmed through record reviews, staff interviews, and direct observation.
Two residents were transferred to different rooms without receiving the required written notice or explanation prior to the move. The Social Worker confirmed that written notification was not provided before the room changes.
A resident who is cognitively intact and receives dialysis was not provided showers according to her stated preferences, despite communicating her desire for afternoon and Sunday showers to staff. She was instead scheduled for showers during the night shift, leading to multiple refusals due to unsuitable timing. Staff confirmed awareness of her preferences, but no changes were made to accommodate her requests.
Two residents refused their breakfast trays, and the CNA removed the meals without offering alternative options. The CNA stated that an alternative was not offered because one resident typically prefers sweets for breakfast. The DON confirmed that staff are trained to offer substitutes if residents are unhappy with the meal served.
Three residents had incomplete or invalid POST forms in their medical records, including missing physician signatures, phone numbers, and license numbers, as well as a lack of required signatures from a legal decision maker despite multiple care conferences. The Director of Social Services confirmed these documentation deficiencies.
Damaged Wall and Stained Grout in Resident Shower Room
Penalty
Summary
Surveyors identified a deficiency related to the resident right to a safe, clean, comfortable, and homelike environment in one of two resident shower rooms on the [NAME] Fort Hall. During observation of the central shower room on the 300-400 Hall, the surveyor noted a damaged area of the wall that had been covered with black tape, as well as stained and discolored tile grout in the shower stall. These environmental issues were directly observed by the surveyor on the same day and were subsequently verified in an interview with the facility’s Director of Plant Maintenance. The facility Administrator also acknowledged these findings during the on-site observation and again at the exit conference. No specific residents, medical histories, or clinical conditions were mentioned in relation to the use of this shower room; the deficiency pertains to the physical condition and cleanliness of the shower environment itself.
Failure to Maintain Environment Free from Accident Hazards
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents in multiple areas. In the day room at the end of the hall, Sani wipes (purple top) cleaners were left on top of vending machines, accessible to residents, despite staff acknowledging they should not be left there. In the Internet cafe/storage area, which is open to residents and also used for staff training, there were multiple pieces of equipment such as beds, lifts, pumps, chairs, and a broken picture frame with sharp edges on the counter, all posing hazards. Additionally, exposed wiring was observed in a wall box without a cover outside a resident room, with staff reporting the wires had been exposed for some time due to ongoing hallway repainting. These conditions were observed during the survey and had the potential to affect more than one resident, with a facility census of 116 at the time.
Infection Control Lapses: Improper PPE Storage and Signage
Penalty
Summary
Surveyors identified multiple infection prevention and control deficiencies within the facility. Two open soda cans were observed on a PPE cart outside a resident's room, compromising the sanitary condition of the PPE area. Additionally, three lift pads were found left exposed on top of a clean linen cart, rather than being stored inside and under cover as required. Furthermore, PPE/EBP precaution signs were posted on multiple doors without specifying which resident the precautions applied to, leading to confusion among staff regarding proper infection control procedures. These issues were confirmed through staff interviews, which revealed uncertainty and lack of adherence to established protocols.
Soiled Incontinence Briefs Left in Resident Rooms
Penalty
Summary
Staff failed to provide treatment and care in accordance with professional standards by leaving soiled incontinence briefs in resident rooms after providing care. Two cognitively intact residents, both with documented capacity to make decisions, reported that soiled briefs belonging to their roommates were left on the floor or in the room, resulting in unpleasant odors. These incidents were confirmed through resident grievances and interviews, with both residents stating that the issue persisted despite some improvement. Anonymous staff interviews corroborated the residents' reports, with multiple staff members acknowledging that soiled briefs continued to be left in resident rooms or trash cans, contrary to facility protocol. The ongoing nature of the problem was noted by both residents and staff, indicating that the deficiency was not isolated but rather a recurring issue affecting the cleanliness and environment of resident rooms.
Improper Storage of Garbage and Medical Waste
Penalty
Summary
The facility failed to properly store garbage and refuse, as evidenced by an observation of the dumpster area that was found to be polluted with garbage and used medical supplies. This issue was confirmed during an interview with the Administrator, who verified the presence of trash and medical supplies on the ground around the dumpster. The deficiency has the potential to affect all residents in the facility, which had a census of 107 at the time of the observation.
Failure to Follow Through with Medication Error Correction Plan
Penalty
Summary
The facility failed to follow through with its plan of correction after a medication administration error was identified involving ten residents. A Registered Nurse (RN) did not administer physician-ordered medications to these residents during several consecutive night shifts. The error was discovered when the Director of Nursing (DON) conducted a random audit of the medication cart and found unopened, dated medication packets that should have been administered. Further review of the Medication Administration Report (MAR) revealed that the medications had been documented as given, despite not being administered. The residents affected had a range of medical conditions, including dementia, hypertension, diabetes, atrial fibrillation, congestive heart failure, depression, schizophrenia, COPD, hypothyroidism, and others. The medications missed included treatments for these conditions, such as insulin, anticoagulants, antihypertensives, antidepressants, supplements, and pain medications. The incident was reported to the appropriate medical professionals, pharmacy, and regulatory agencies, and the residents or their medical decision-makers were notified. Despite identifying the deficiency and outlining a plan of correction, the facility did not provide documentation that staff re-education or medication cart audits were completed as required. This lack of follow-through was confirmed by both the DON and the Regional Director of Clinical Operations, who acknowledged the absence of records for these corrective actions.
Failure to Implement Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in a widespread issue with gnats throughout the building. During the initial tour, gnats were observed on the walls and ceiling of a resident room, with a window left open and a plug-in insect trap containing multiple gnats. The Central Supply Coordinator confirmed the presence of gnats in the dining room and on resident trays, and noted that rooms where residents had episodes of incontinence were particularly affected. The exterminator reported that he had not been contacted to address the gnat problem prior to the survey, despite verifying their presence throughout the facility. The Administrator acknowledged attempts to address the issue using plug-in traps and by opening windows, and confirmed that a resident had been moved out of an affected room due to the infestation. Additionally, a resident reported having to kill gnats herself and expressed dissatisfaction with delayed garbage removal in her room, stating she had not received any follow-up from the Administrator after raising her concerns.
Deficient Food Safety and Sanitation Practices in Kitchen and Equipment
Penalty
Summary
During an inspection of the facility's kitchen, surveyors observed multiple failures to maintain food safety and sanitation standards. In the walk-in refrigerator, an opened container of cottage cheese was found without a label or date, and several heads of lettuce were brown and spoiled. The walk-in freezer contained boxes of hamburger patties, waffles, and french toast that were left open to the air. In dry storage, four dented cans of peaches and soups were found in circulation. The microwave had dried food debris inside, and the floors under the stove and sink area were littered with food and debris. Additionally, the stove and the exterior surfaces of refrigerators and freezers were unclean. These issues were confirmed by the Kitchen Account Manager during the tour. Further deficiencies were identified with the facility's dishwasher and ice machines. Records showed that the dishwasher's final rinse temperature had been below the recommended 180 degrees for nearly a month, yet the dietary staff continued to use the machine despite being educated on proper protocols for hand washing when temperatures were inadequate. The Kitchen Account Manager confirmed the dishwasher was not functioning properly. Additionally, a tour of the pantry areas revealed that the ice machine drains lacked the required air gap, with drain pipes touching the drains due to broken brackets, a fact confirmed by the Maintenance Director.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies. One incident involved a resident with cognitive impairment who entered the dining room with a soiled brief, placed it on the table, and began playing in feces in the presence of other residents and two activity aides. The aides did not intervene, and staff from another hallway declined to assist when asked by residents. Eventually, another resident located a CNA from the appropriate hallway, who then intervened to address the situation. Multiple cognitively intact residents confirmed the sequence of events and the lack of timely staff response. Additional observations revealed environmental sanitation issues, including overflowing trash and soiled linen barrels with lids off in a hallway, and soiled linens left on the floor near a resident room. These conditions were acknowledged by staff present at the time, who confirmed that the waste containers had been in that state for several hours. A further deficiency was observed during wound care for a resident requiring Enhanced Barrier Precautions (EBP). The resident, who had multiple wounds including venous stasis ulcers, a diabetic foot ulcer, and an abscess, did not have EBP signage posted in the room. The nurse practitioner and LPN performing wound care did not don appropriate PPE before entering the room or providing care. Staff interviews confirmed that the resident should have been on EBP, but the signage and orders were not in place at the time of the observation.
Black Substance and Debris Found on PTAC Units and Ceiling Vents
Penalty
Summary
The facility failed to maintain a safe and homelike environment for its residents, staff, and the public, as evidenced by the presence of a black substance around packaged terminal air conditioner (PTAC) units in the dining rooms and on ceiling vents throughout the building. During an observation, surveyors noted the black substance and debris on and around these units and vents. The Maintenance Director confirmed the presence of the black substance and debris during interviews conducted at the time of the observations. These findings had the potential to affect all residents in the facility, which had a census of 107 at the time of the survey.
Failure to Ensure Medication Regimens Are Free from Unnecessary Drugs
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary drugs, as evidenced by the administration of medications without appropriate diagnoses or indications. For one resident, donepezil and trazodone were prescribed for dementia and depression, respectively, despite no documented diagnoses or supporting physician notes for either condition. The Director of Nursing confirmed the absence of these diagnoses and related documentation. Another resident was prescribed doxycycline for cellulitis despite a documented allergy to the medication, and the facility did not notify the physician or obtain a documented rationale for its use. The consultant pharmacist also missed this irregularity during their review, as the order was placed after the review was completed. Additionally, two other residents were found to be receiving anti-seizure medications (levetiracetam and zonisamide) without current diagnoses of seizures or epilepsy, and their care plans did not address seizure management. The Director of Nursing confirmed the lack of appropriate diagnoses for both residents. These findings were based on record reviews and staff interviews, and they demonstrate a pattern of medication administration without proper clinical justification or documentation.
Failure to Provide Menu Items Due to Food Shortages
Penalty
Summary
The facility failed to ensure that menus were followed and that required food items were available for meal preparation, resulting in residents not receiving the meals as planned. Multiple observations and interviews revealed that residents frequently did not receive menu items due to the facility running out of food, such as milk, bread, and specific entrees. One resident reported not having milk for several days and receiving chocolate milk or orange juice as substitutes for cereal. The dietary manager confirmed that when menu items were unavailable, they simply informed the nurse aides and did not post menu changes for residents to see. Meal tickets listed specific items, but residents received different food, such as pork roast instead of chicken thigh, and did not receive items like rolls or brownies as indicated on the menu. Medical record review showed that the affected resident was on a regular diet. Observations confirmed that the resident did not receive milk with breakfast on multiple occasions, despite it being listed on the meal ticket. Staff interviews verified that the facility had been out of milk and were waiting for a delivery. The lack of adherence to the planned menu and failure to provide required food items affected more than a limited number of residents, as indicated by the facility census.
Failure to Ensure Dignified Dining Experience and Timely Response to Resident Needs
Penalty
Summary
The facility failed to protect and promote a dignified dining experience and did not respond to a resident's call light in a timely manner. During a Thanksgiving meal, a resident with severe cognitive impairment entered the dining room with a soiled brief, placed it on the table, and began playing in the feces. Multiple cognitively intact residents witnessed the incident and reported that two activity aides present did not intervene. When one resident sought help from staff on another hallway, she was told it was not their problem, and only after further effort was a CNA found to assist. The incident was corroborated by resident and staff interviews, and it was unclear whose brief was involved. The event disrupted the dining experience for all present and failed to maintain the dignity of the resident involved. In the overflow dining room, all residents were observed eating lunch off serving trays, as staff did not remove the trays after serving. A nurse aide confirmed that this was a daily occurrence. Additionally, during another meal observation, some residents at a large table received their meals significantly later than others. One resident was observed crying and repeatedly asking for food, not receiving her meal until much later, while another resident questioned the delay and also received her meal late. These delays in meal service contributed to a lack of dignity and comfort for the residents involved. The facility also failed to respond promptly to a resident's call light. A resident experiencing gastrointestinal distress used her call light and waited approximately 19 minutes for assistance. The nursing assistant who responded explained that all aides were busy with care for other residents. Other residents interviewed reported that response times for assistance could be as long as 30 minutes, with one resident stating he was only able to avoid soiling his bed because he had a catheter. These findings indicate a pattern of delayed response to resident needs and a lack of timely assistance.
Failure to Address and Respond to Resident Council Grievances
Penalty
Summary
The facility failed to ensure that resident council grievances, issues, and concerns were acted upon promptly and that residents received a rational response. Resident council meeting minutes indicated that concerns and issues were brought up, but these were not documented in the minutes, nor were they tracked or followed up on. The activities coordinator reported that she wrote down concerns and passed them to the Nursing Home Administrator, but these were not included in the official meeting minutes. The Administrator was unable to provide documentation of grievances or concerns from past or present meetings and confirmed that he was not aware of specific requests, such as the repeated request to have the Soup of the Day placed back on the menu. Multiple residents, all of whom were cognitively intact, confirmed that they had repeatedly raised the same request during resident council meetings over several months without receiving any feedback or resolution. A review of the facility's grievance log and residents' medical charts did not show any record of these concerns being formally documented. Staff interviews further confirmed that the process for handling and responding to resident council concerns was not being followed, resulting in a lack of communication and resolution for resident-raised issues.
Failure to Secure and Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records by leaving diagnosis sheets and mini nutritional assessments in a clear acrylic wall file holder outside the Medical Records office. These documents, which contained confidential information, were accessible to anyone passing by. The forms included diagnosis sheets for several residents and mini nutritional assessments, all printed by an MDS RN. The Medical Records Coordinator confirmed during an interview that the documents were accessible and contained private information.
Dining Room Temperature Not Maintained at Comfortable Level
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not keeping the dining room at a comfortable temperature. During an observation, several residents were noted to be cold while in the dining room: one resident was shivering and required a sweater, another verbally expressed feeling cold, a third wore extra layers and brought a blanket, and a fourth had a blanket wrapped around her. Upon request, the Maintenance Director measured the dining room temperature and found it to be 65.5 degrees Fahrenheit, below the minimum standard of 71 degrees Fahrenheit. The Maintenance Director indicated that staff sometimes turn on the air conditioner because they feel hot, which contributed to the low temperature in the dining area.
Failure to Address and Document Resident Grievances
Penalty
Summary
The facility failed to promptly address and resolve verbal grievances raised by multiple cognitively intact residents regarding various concerns. Several residents repeatedly requested the return of the Soup of the Day to the menu during resident council meetings, but their requests were neither acknowledged nor documented in the facility's grievance log. The Administrator was unaware of these requests and confirmed that no written grievances had been submitted or followed up on. Additionally, a resident reported issues with gnats in her room, burnt food, and garbage not being removed for several days. Despite discussing these concerns directly with the Administrator, there was no evidence of documentation or follow-up, and the issues were not recorded in the grievance log. Another resident reported missing personal property to housekeeping and laundry staff on multiple occasions, but her concerns were not documented or escalated. A housekeeper confirmed receiving these complaints but did not complete grievance forms or notify other facility staff. In all cases, the residents involved were noted to be cognitively intact and capable of accurately recalling the events. The facility's failure to document, investigate, and respond to these verbal grievances constitutes a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal.
Failure to Revise and Individualize Care Plans for Showers, Wound Care, and Repositioning
Penalty
Summary
The facility failed to revise and individualize comprehensive care plans for several residents in the areas of showers, wound care, and turning and repositioning. Multiple residents expressed preferences for showers over bed baths, but their care plans did not specify these preferences or document their history of refusals. For example, three residents who preferred showers did not have this preference or their refusals reflected in their care plans, despite staff and the Director of Nursing confirming these preferences and occurrences. Additionally, the care plan for a resident with a stage IV pressure ulcer to the sacrum did not identify the current wound status or include interventions or tasks for wound care, even though there were active orders and observations confirming the presence of the wound. The care plan only referenced previous or unrelated skin issues, failing to address the current stage IV ulcer and its required care. Another resident with a stage III pressure ulcer to the back, who was non-verbal and immobile, did not have care plan interventions for turning and repositioning to prevent worsening of the ulcer. Although staff reported turning the resident and there was a charting task for rolling, the care plan lacked documentation of these interventions. The Director of Nursing confirmed that the care plan should reflect the standard practice of turning and repositioning for immobile residents with pressure ulcers.
Failure to Administer Medications and Monitor Resident Care per Orders
Penalty
Summary
A facility failed to provide resident-centered care and services in accordance with physician orders and professional nursing standards for multiple residents. Specifically, a Registered Nurse did not administer prescribed medications to ten residents during several consecutive night shifts, despite documenting in the Medication Administration Report (MAR) that the medications had been given. This discrepancy was discovered during a random audit of the medication cart, which revealed unopened, dated medication packets still present. The medications missed included treatments for conditions such as dementia, hypertension, diabetes, depression, pain, and other chronic illnesses. Additionally, a resident experienced a significant weight loss of 10.3% within one month, dropping from 208 to 186.6 pounds. Facility policy required re-weighing the resident if a five-pound fluctuation was noted, but this was not done on two occasions when such fluctuations occurred. The Director of Nursing confirmed that the policy was not followed and that the weight documentation supported the need for re-weighing. Another resident with an order for enteral feeding was found to have unclear documentation regarding the administration of 90ml pre- and post-feeding flushes. During an interview, the DON initially misidentified the flush as a nutritional supplement before correcting herself to indicate it was water for tube flushes. These findings collectively demonstrate failures in medication administration, monitoring of significant weight changes, and clarity in following physician orders for enteral feeding.
Unattended and Unlocked Medication and Treatment Carts Create Accident Hazards
Penalty
Summary
Surveyors observed that the facility failed to ensure medication and treatment carts were kept locked and attended, as required to maintain a safe environment free from accident hazards. On multiple occasions, three medication carts and one treatment cart were found unlocked and unattended in various hallways. Specifically, two medication carts were left unattended and unlocked at the nurses station on the 100/200 hallways, with confirmation from the responsible LPNs upon their return. Another medication cart was later found in a similar state at the nurses station on the 100 hallway, with confirmation from staff regarding responsibility for the cart. Additionally, during tracheostomy care in a resident's room, an LPN left the treatment cart unlocked and unattended in the hallway after retrieving supplies and closing the resident's door. This was confirmed by the Regional Director of Clinical Operations, who acknowledged that the treatment cart should have remained locked when not in use. These lapses in securing medication and treatment carts created accident hazards in areas accessible to residents.
Insufficient Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient direct care staff to meet the needs of all residents, as outlined in its own facility assessment. On multiple reviewed dates, the number of Nurse Aides present on both day and night shifts was consistently below the minimum staffing levels established by the facility. For example, on several days, only six to nine Nurse Aides were present on day shift, and as few as four on night shift, despite the facility assessment indicating a need for ten to twelve on day shift and eight to ten on night shift. These staffing shortages were confirmed through punch in and out reports and acknowledged by the Director of Nursing during an interview. As a result of these staffing deficiencies, several care issues were identified. Dependent residents were not receiving showers, and one resident was not showered at their preferred time. Additionally, a resident with a Stage III pressure ulcer was not being turned and repositioned as required, and another resident experienced significant weight loss without interventions. These findings demonstrate that the facility did not deploy enough nursing staff to meet the care needs of all residents as required.
Lack of Physician Response to Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that a physician responded to recommendations made by a licensed pharmacist regarding residents' medication regimens. For one resident, pharmacy recommendations to reassess a PRN order for Lorazepam and to address possible duplicate orders for Tramadol and Ativan were documented, but there was no evidence that the physician acknowledged, agreed, disagreed, or provided any rationale for these recommendations. Additionally, for another resident, the physician did not provide a rationale for the use of a medication to which the resident had a documented allergy. These deficiencies were confirmed during a review of records with the Assistant Director of Nursing, where it was noted that there were no physician signatures, dates, or documented rationales in response to the pharmacist's recommendations.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain adequate nutritional status for a resident who experienced a significant weight loss of 10.3% within one month. The resident's weight dropped from 208 pounds to 186.6 pounds over a 30-day period, which meets the criteria for significant weight loss. The resident was on a regular diet with diabetic condiments and no salt packet, and there were no supplements, snacks, or additional protein sources ordered. Meal intake records indicated the resident typically consumed between 51-100% of meals. Despite the documented weight loss, there were no new dietary assessments or progress notes entered after the weight loss was recorded, and the DON confirmed the absence of a dietary assessment in response to the weight loss.
Delayed Physician Response to New Onset Symptoms
Penalty
Summary
The facility failed to ensure that a physician or their delegate responded in a timely manner to a new onset of symptoms in a resident. Specifically, a nursing assistant reported blood in a resident's catheter bag to an LPN, who assessed the catheter and found no abnormalities, with the resident reporting no pain or discomfort. The LPN sent a secure message to both the nurse practitioner and the medical director and attempted to contact the resident's medical power of attorney, but neither the nurse practitioner nor the medical director responded to the message. The resident was later seen by the nurse practitioner two days after the initial report, at which time the resident was found to be acutely hypoxic with Cheyne-Stokes respiration and cyanosis, and subsequently experienced cessation of respiration within ten minutes.
Failure to Consistently Turn and Reposition Immobile Resident with Pressure Ulcer
Penalty
Summary
A deficiency was identified when an immobile, non-verbal resident with a stage III pressure ulcer on her left back was not turned and repositioned according to standard nursing practice. The resident, who is totally dependent on staff for mobility and has contractures preventing self-repositioning, had a care plan and physician orders for wound care but lacked documented interventions or tasks for regular turning and repositioning to prevent further skin breakdown. Staff interviews confirmed that there was no routine charting system for turning, and although some staff reported turning the resident, documentation did not support consistent implementation of this intervention. A review of the resident's records over a 30-day period revealed that she was turned and repositioned only 51 times, far below the expected 360 opportunities if performed every two hours as per standard practice. There were also days with no documentation of turning or repositioning. The DON confirmed that the resident had not been turned and repositioned according to standard practice, which is necessary to prevent new or worsening pressure ulcers.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to assist residents with activities of daily living, specifically showers, for residents who were unable to perform these tasks independently. For one resident, although the care plan and shower schedule indicated showers were to be provided twice weekly, documentation showed that only five out of eight scheduled showers were given over a thirty-day period, with no refusals recorded and no care plan documentation of a history of refusals. This resulted in a nine-day gap without a shower for this resident. Another resident, also scheduled for twice-weekly showers, received only two out of eight scheduled showers in the same period. While two refusals were documented, there were still significant gaps in care, including a seventeen-day period without a shower. Both residents expressed a preference for showers over bed baths and reported not receiving showers as ordered. These findings were confirmed with the Director of Nursing.
Incomplete PASARR Documentation for Resident Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Pre-Admission Screening (PAS) accurately reflected all pre-admission diagnoses. Record review showed that the resident had diagnoses of Major Depression Disorder and Epilepsy. However, the PAS completed for the resident did not include the Epilepsy diagnosis under the section for current diagnoses, and only listed major depression under the section for major mental illness or suspected mental illness. During staff interview, the Director of Social Services confirmed that the resident's Epilepsy diagnosis had not been captured on the PAS.
Failure to Implement and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to fully implement and update care plans for three residents, resulting in deficiencies related to monitoring, documentation, and individualized interventions. For one resident with behavioral issues, staff did not consistently monitor and document behaviors as required by the care plan and physician orders, with specific dates noted where monitoring was missed. The Director of Nursing confirmed these lapses in behavior monitoring. Another resident, who had a documented incident of physical aggression toward a roommate, did not have this history reflected in her care plan, and the DON acknowledged the care plan was not updated to include this information. Additionally, a resident with legal blindness had a care plan that lacked specific interventions to address her needs, such as guidance on meal tray arrangement and organization of personal items for accessibility. Observations showed that this resident was not engaged in activities or provided with individualized support, despite her care plan indicating encouragement for participation. Staff interviews confirmed the absence of tailored interventions and engagement for this resident.
Failure to Provide Written Notice Before Room Transfers
Penalty
Summary
The facility failed to honor residents' rights by not providing written notice, including the reason for the change, prior to transferring two residents to different rooms. Record reviews showed that one resident was moved from one room to another on 11/16/24, and another resident was moved on 11/29/24, with neither receiving the required written notification before the room change. During an interview, the Social Worker confirmed that no written notice was given to either resident before their transfers.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination by not providing showers according to her stated preferences. The resident, who is cognitively intact with a BIMS score of 15 and has been deemed capacitated by a physician, reported that she often had to repeatedly request showers and still did not receive them at her preferred times. She expressed that she wanted showers in the afternoons and an extra shower on Sundays to be clean for dialysis on Mondays, but was instead scheduled for showers on the night shift, which she found unsuitable due to cold temperatures and the inconvenience of having wet hair before leaving for dialysis. Record review showed multiple documented refusals of showers by the resident, with no reasons noted in the progress notes. During interviews, the resident explained her refusals were due to the timing of the showers being too early in the morning or too late at night, which did not align with her preferences. Staff interviews confirmed that the resident had communicated her desired changes in shower times to both nurses and aides, but her preferences were not accommodated, and her schedule remained unchanged.
Failure to Offer Meal Substitutes When Residents Refused Food
Penalty
Summary
During the morning meal service on the 400 Hall, two residents refused their breakfast trays by stating, "No thanks." The certified nursing assistant (CNA) responsible for meal delivery removed the trays from their room but did not offer any alternative food options. When questioned, the CNA explained that an alternative was not offered because one of the residents typically only likes sweets for breakfast and would have accepted the meal if it had been a cinnamon roll. The Director of Nursing later confirmed that all aides are trained to offer residents the opportunity to receive a substitute if they are unhappy with the meal served. This incident demonstrates that the facility failed to provide residents with the opportunity to receive a substitute meal when they refused the food items offered, as required by facility policy and training.
Incomplete and Invalid POST Forms in Resident Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three out of four residents reviewed, specifically regarding their Physician Orders for Scope of Treatment (POST) forms. For one resident, both the electronic and original POST forms were missing the physician's signature, phone number, and license number, rendering the form invalid. Another resident's POST form was missing the physician's phone number in both the electronic chart and the original document, which would prevent timely contact with the physician if needed. A third resident's POST form indicated that verbal consent was accepted from the legal decision maker, but the facility did not obtain an original signature, despite the legal representative's participation in subsequent care conferences where the POST form was reviewed. In each case, the Director of Social Services confirmed the deficiencies in the documentation, acknowledging that the forms were incomplete or invalid due to missing required information.
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 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.
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.
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 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.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
