Salem Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, West Virginia.
- Location
- 255 Sunbridge Drive, Salem, West Virginia 26426
- CMS Provider Number
- 515071
- Inspections on file
- 21
- Latest survey
- June 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Salem Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control failures, including a resident's suction machine left uncleaned and uncovered, wheelchairs and a geri-chair with torn arm pads exposing inner padding, inoperable laundry room ventilation, soiled linen and trash left in shower rooms, and improper use of the facility van to transport soiled linen without disinfection. The facility also lacked proper infection surveillance and water management protocols, with no documentation of flushing or maintenance of fixtures in unoccupied rooms.
Multiple deficiencies were observed, including broken and missing fixtures, unfinished drywall, stains, and damaged furniture in several resident rooms. In the kitchen, the exhaust fan and air conditioning were not working, causing excessive heat, and several pieces of equipment were broken or nonfunctional. The shower rooms had non-operational ventilation, musty odors, and visible black and brown substances on surfaces and equipment. Staff confirmed the ongoing nature of these issues.
Kitchen staff lacked training on the use of the fire compression system, as observed when they were unable to identify how to manually activate the fire hood during a survey. The maintenance department had to demonstrate the activation process, revealing that staff were previously unaware of the correct procedure.
Surveyors identified multiple deficiencies in food storage and handling, including open and unlabeled food items, expired products, improper storage of staff personal drinks, unclean kitchen areas, and inadequate hair/beard covering by kitchen staff. Additionally, kitchen and nourishment room temperatures were found to be above recommended levels, and food items were left uncovered and unlabeled, all in violation of professional standards and facility policy.
Resident wheelchairs were observed lined up on both sides of a hallway, blocking a direct walking path. The facility administrator confirmed the insufficient space and lack of a clear passage during staff interview.
The facility failed to maintain operational venting systems in both laundry and shower rooms, resulting in unsanitary and uncomfortable conditions. Staff confirmed that the venting systems had been non-functional for over a month, leading to high humidity, musty odors, and the potential for microorganism transfer between dirty and clean areas.
The facility did not maintain operational ventilation systems in the shower rooms and dirty laundry room, resulting in humid, musty conditions and visible substances on shower surfaces and chairs. Staff confirmed the ventilation had been non-functional for over a month, and the lack of negative pressure in the laundry area potentially allowed microorganism transfer between rooms.
Multiple residents reported that meals were bland, cold, and not served according to individual preferences, with food lacking seasoning and visual appeal. Care plans did not document dietary preferences or interventions for meal satisfaction, and the kitchen environment was unsanitary with broken equipment. Despite complaints, requested test trays for surveyors were not delivered, and staff failed to communicate or follow up on these requests.
A resident left the facility for a procedure and did not return, but the required transfer or discharge notice was not completed. The DON and Administrator confirmed that no documentation was provided, as staff did not think it was needed in this case.
Surveyors found that garbage and refuse were not properly disposed of, with overflowing trash cans and boxes on the kitchen floor, expired food containers left on counters, and multiple issues in the dumpster area including blocked drainage pipes and scattered trash and gloves. Staff confirmed the trash overflow and acknowledged the problems in the dumpster area.
Multiple Infection Control Failures in Facility Equipment, Laundry, and Water Management
Penalty
Summary
The facility failed to maintain infection control standards in multiple areas, as evidenced by direct observations and staff interviews. One incident involved a resident's suctioning machine, which was found with a half-full canister of a clear/yellow thick substance and an uncovered cord exposed to the environment. The responsible RN confirmed the machine had not been cleaned or covered after use and had not noticed its condition prior to the observation. Additionally, several resident-assigned wheelchairs and a geri-chair in a hallway were observed with cracks and tears in the arm pads, exposing the inner padding. The facility's Infection Preventionist acknowledged these as infection control issues. The laundry room's ventilation system, designed to maintain negative pressure and prevent cross-contamination between dirty and clean laundry areas, was found to be inoperable for over a month. The air conditioning unit in the clean laundry room was also not functioning. Housekeeping staff and the Regional Director of Maintenance confirmed the ongoing issues with the ventilation system. Furthermore, soiled linen and trash were not removed from shower rooms between uses, and the shower rooms were noted to be humid, musty, and had visible black substance on the walls, which was confirmed by maintenance staff during inspection. The facility also failed to implement proper infection control protocols when using the facility's transport van to carry soiled linen to an offsite laundromat. The van was used to transport soiled linen and then residents, without any arrangements for cleaning or disinfecting the van between uses. The Infection Preventionist was unaware of this practice. Additionally, the facility did not maintain adequate infection surveillance or implement water management protocols, such as flushing and draining dead legs or fixtures in unoccupied rooms. Maintenance and administrative staff confirmed the absence of logs or documentation for these activities, and unoccupied rooms were not properly maintained during periods of vacancy.
Environmental Deficiencies in Resident Rooms, Kitchen, and Shower Rooms
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's environment, including resident rooms, the kitchen, and shower rooms. In several resident rooms, there were broken or missing toilet seats and tank lids, chipped and unfinished drywall, scuff marks, peeling paint, brownish stains on floors, loose bed foot rails, broken bedside table drawers, and black spots or stains on walls and toilets. These issues were confirmed by the facility administrator during a walkthrough, who acknowledged the presence of these environmental deficiencies. In the kitchen, the exhaust fan above the stove was not working, the air conditioning was inoperable resulting in temperatures exceeding 91 degrees, and staff were observed perspiring heavily during meal preparation. Additional issues included a broken convection oven, a non-functional upright freezer, a broken sink drain lever, a spill left on the floor, and a broken trash receptacle foot pedal at the handwashing station, which prevented staff from lifting the lid without contamination. The kitchen account manager confirmed the duration of these problems and the lack of timely repairs. In the shower rooms, the ventilation system was not operational, resulting in humidity and a musty odor, with black substances on the shower stall walls and brown substances on shower chairs. Staff interviews confirmed the venting system had been nonfunctional for over a month.
Failure to Train Kitchen Staff on Fire Compression System Use
Penalty
Summary
Kitchen staff were not provided with education or training on how to use the fire compression system in the facility's kitchen. During an observation, it was noted that there was no manual pull chain for the fire system, and when questioned, kitchen staff were unaware of how to manually activate the fire hood to extinguish a fire. The maintenance department later demonstrated to both staff and surveyors the button used to activate the fire hood, confirming that kitchen staff did not previously know how to operate the fire compression system.
Improper Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple failures in food storage and handling practices within the facility's kitchen and nourishment pantries. In the kitchen pantry, spices and a corn muffin mix box were left open and exposed, and a box of elbow noodles was stored without an opening or expiration date. Additionally, expired spaghetti was found in the pantry. In the cooler, staff personal drinks were stored alongside facility food items. The kitchen area was found to have food spills on the floor that were not cleaned, and a metal basin pan was left on the floor near the stove. Utensil drawers contained dried food spots and utensils were not stored in a uniform manner. The chef was observed with hair and beard not fully covered, wearing only a hat with hair exposed at the neck. The kitchen temperature was recorded at 91 degrees due to a broken air conditioner, and the cooler temperature was elevated at 51 degrees, which was acknowledged by both the Kitchen Account Manager and the facility administrator. In the nourishment pantries, the refrigerator in Nutrition Room One was consistently above the recommended temperature, with logs showing temperatures of 42-44 degrees over several days. A bowl of oatmeal was left uncovered and unlabeled on the counter, and staff reported that the room became excessively hot when the ice machine was running, affecting the refrigerator's ability to maintain safe temperatures. In another nutrition room, a tray of medicine pudding cups was found in the refrigerator without labels or dates, which was confirmed by the Nurse Infection Preventionist as having come from food service in that condition. These findings indicate a pattern of non-compliance with professional standards for food storage and handling, as well as facility policy requirements.
Obstructed Hallway Due to Wheelchair Placement
Penalty
Summary
Facility staff failed to provide sufficient hallway space and equipment, as evidenced by resident wheelchairs lined up on both sides of the Hill Top Front Hallway, obstructing a direct walking path. This was observed during a random opportunity for discovery, with the hallway arrangement leaving no clear passage for those walking through. The facility administrator acknowledged the lack of adequate space and direct path during a staff interview. No specific details about individual residents' medical history or conditions at the time of the deficiency were provided in the report.
Non-Operational Ventilation in Laundry and Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in both the laundry and shower rooms. During an inspection, it was observed that the venting system responsible for maintaining negative pressure in the dirty laundry room was not operational, and the air conditioning unit in the clean laundry room was also non-functional. Housekeeping staff confirmed that the venting system had been out of service for over a month, and the Regional Director of Maintenance acknowledged the issue. The lack of negative pressure in the dirty laundry room could allow microorganisms to transfer into the clean laundry room when the connecting door is opened. In the shower rooms, the venting system was also found to be non-operational, resulting in high humidity and a musty odor. The Regional Maintenance Director confirmed the conditions and stated that repairs were underway. A nursing assistant reported that the venting system in the shower rooms had not been working for over a month. The Administrator and Director of Nursing were notified of the issues with the shower rooms.
Inadequate Ventilation in Shower and Laundry Rooms
Penalty
Summary
The facility failed to ensure adequate ventilation in both the shower rooms and the dirty laundry room. During an inspection, it was observed that the venting systems in the two shower rooms were not operational, resulting in humid conditions and a musty odor. The shower stall walls had a black substance present, and several shower chairs had a brown substance on the underside of the seats and on the chair legs. Staff interviews confirmed that the venting system in the shower rooms had not been operational for over a month. In the dirty laundry room, the venting system responsible for maintaining negative pressure was also found to be non-functional. This failure potentially allowed the transfer of microorganisms from the dirty laundry room into the clean laundry room whenever the connecting door was opened. Housekeeping staff confirmed that the venting system in the laundry room had not been operational for over a month, and the Regional Director of Maintenance acknowledged the issue during the inspection.
Failure to Provide Palatable, Appealing, and Properly Served Meals
Penalty
Summary
The facility failed to ensure that food and drink were palatable, visually appealing, and served at a safe and appetizing temperature, as evidenced by observations, staff and resident interviews, and record reviews. Multiple residents reported that meals were bland, cold, and not served according to their individual preferences. Food was described as lacking seasoning, being overcooked or undercooked, and visually unappealing, with no garnishes or condiments provided. The care plans reviewed did not document residents' dietary preferences, dislikes, or specific modifications, and there were no interventions listed to support resident satisfaction with meals. The dietary manager acknowledged that resident food preferences were not routinely gathered, except during infrequent walk-throughs and committee meetings, and relied on CNAs to relay concerns. Environmental observations in the kitchen revealed poor sanitation, broken equipment, inadequate refrigeration, and lack of ventilation or air conditioning, further compromising food quality and safety. Despite resident complaints about food quality, the facility failed to provide requested test trays for surveyors to assess food temperature, appearance, and taste. The dietary manager admitted to not following up on the delivery of test trays, and the survey team was not notified when trays were placed on the meal cart, resulting in the trays not being received. Staff interviews confirmed the oversight, and the facility administrator acknowledged the breakdown in communication. These failures were observed for all five residents reviewed for food satisfaction, with a facility census of 87.
Failure to Provide Transfer/Discharge Notice Prior to Resident Leaving
Penalty
Summary
The facility failed to provide the required transfer or discharge notice prior to a resident leaving the facility. During a record review, it was found that there was no documentation of a transfer or discharge notice for a resident who left the facility for a procedure and subsequently went home. When documentation was requested, both the DON and the Administrator confirmed that no transfer or discharge paperwork had been completed for this resident, as staff did not believe it was necessary in this situation. This deficiency was identified for one of two residents reviewed for closed records related to hospitalization and discharge.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Surveyors observed improper disposal of garbage and refuse in multiple areas of the facility. In the kitchen, boxes and trash were found on the floor next to an overflowing trash can, and expired food containers were stacked on the side sink counter during lunch preparation. In the dumpster area, three dumpsters were inspected: one had a broken tree branch protruding from the drainage pipe, blocking drainage; another had a garbage bag and used clear gloves scattered on the ground behind it; and a third had a plastic garbage bag with trash protruding from the drainage pipe, also blocking drainage. Staff interviews confirmed that the kitchen trash can was overflowing and that expired food was awaiting disposal, and the Kitchen Account Manager acknowledged the issues in the dumpster area, stating she was unaware of the blocked drains and that the littered gloves were not from the kitchen.
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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