Shenandoah Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charles Town, West Virginia.
- Location
- 50 Mulberry Tree Street, Charles Town, West Virginia 25414
- CMS Provider Number
- 515167
- Inspections on file
- 20
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Shenandoah Center during CMS and state inspections, most recent first.
A resident exhibited repeated behavioral issues, including entering other residents' rooms, consuming their food and drinks, and public urination, which were observed and documented by staff. Despite these ongoing behaviors and the need for frequent redirection, the care plan was not updated to reflect or address these concerns.
A facility failed to provide safe dialysis care for a resident by repeatedly taking blood pressure in the arm with an AV fistula, contrary to medical orders. The facility also neglected to perform post-dialysis assessments, as required. Observations showed a lack of signage to alert staff about the restricted limb, and staff interviews confirmed non-compliance with care plans, leading to immediate jeopardy.
Two incidents of abuse and neglect occurred in a LTC facility. An LPN physically abused a resident during a combative episode, while a NA neglected another resident by leaving them in a soiled state. Both incidents were substantiated, and the staff involved were terminated. However, there was no evidence of preventive measures taken for the neglect incident.
A resident in a long-term care facility was mistakenly given 25 units of insulin despite not being diabetic or having an insulin order. The error occurred after a room change, and the nurse failed to verify the resident's identity. The resident's blood sugar was monitored following the incident, but the facility did not document any investigation or corrective measures to prevent future errors. Interviews revealed that the LPN involved was unaware of the room change and did not verify the resident's identity.
The facility failed to provide showers and timely transfers according to residents' preferences and care plans. Several residents reported not receiving showers for over thirty days, despite being scheduled for them. A resident experienced psychosocial harm due to a delay in being transferred from her chair to her bed, causing distress. Records showed inconsistencies in bathing schedules, highlighting a systemic issue in meeting residents' needs.
The facility failed to maintain proper infection control practices, including improper disposal of soiled linen and gloves, inadequate use of PPE in EBP rooms, and improper handling of meal trays and bedpans. These deficiencies were observed by surveyors and confirmed through staff interviews, indicating a potential risk to the facility's residents.
The facility failed to honor the bathing preferences of several residents, with some not receiving showers for over a month despite being scheduled for twice-weekly showers. Residents expressed dissatisfaction, and records confirmed significant gaps in bathing schedules. The DON acknowledged the issue and stated efforts were underway to address it.
A facility failed to keep residents' medical information confidential when an LPN left a computer unattended on a medication cart with resident information visible. The LPN later acknowledged the oversight, and the DON confirmed that the computer should have been locked.
The facility failed to maintain a homelike environment, with multiple resident doors showing visible cracks and rough edges, and a PTAC unit in a resident's room covered in moldlike substance. The resident expressed concerns about allergies, potentially linked to the mold, which was confirmed by the Maintenance Supervisor.
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and personal care needs. A resident's care plan did not include a diagnosis of Dementia, while another's lacked interventions for anxiety disorder. Additionally, several residents reported not receiving showers as per their preferences, and a resident's care plan intervention to avoid taking blood pressure in a specific arm was not followed.
The facility failed to maintain a safe environment by leaving a treatment cart unlocked and unattended in a resident TV room, and unsecured medication at a resident's bedside. An RN confirmed these items should not have been left accessible to residents, unauthorized persons, or visitors.
The facility did not conduct yearly performance evaluations for three Nurse Aides, as identified during a survey. A review of records showed missing evaluations for these aides, and the Administrator confirmed the oversight, acknowledging the need to address the issue.
A facility failed to monitor behavior and side effects for a resident prescribed Lorazepam for anxiety. The resident's MAR showed no monitoring from December 2023 to May 2024, despite instructions to observe for sedation, morning hangover, ataxia, and nausea. The DON confirmed the lack of monitoring during an interview.
A survey found that a facility failed to maintain complete temperature logs for its medication refrigerator from March to July 2024. The facility's policy requires twice-daily temperature checks, but numerous dates were missing records. The Administrator confirmed the logs were incomplete, potentially affecting the care of residents.
The facility failed to discard expired food items, including scalloped potatoes and moldy onions, found in the kitchen's walk-in refrigerator. The Dietary Manager in Training acknowledged the oversight and stated they would dispose of the items. This deficiency had the potential to affect more than a limited number of residents.
The facility failed to maintain a functioning resident call system, as observed during a tour of the 200 and 300 halls where the call light system was turned off and the volume was too low. The Maintenance Assistant confirmed the system was turned off by staff, and the Maintenance Director noted that all call systems had been turned down since his employment began.
The facility failed to notify the State ombudsman of a discharge for a resident. A record review revealed that the resident had been discharged to another facility, but there was no evidence of the required notification being sent. The Administrator confirmed the absence of the notification.
The facility failed to accurately complete MDS assessments for two residents regarding their discharge destinations. One resident was discharged to another LTC facility, but the MDS listed home as the destination. Another resident was discharged to home, but the MDS recorded a short-term general hospital as the destination. These errors were confirmed by the Administrator.
A facility failed to update a resident's care plan when the status of her pressure ulcer changed. The care plan inaccurately listed the ulcer as a Stage 2, despite a skin and wound evaluation indicating it was unstageable. The DON acknowledged ongoing issues with care plan revisions.
A facility failed to provide an adequate activity program for a resident, as observations showed the resident spent long periods in the TV Lounge without engaging in meaningful activities. The resident's care plan required one-to-one visits three times a week, which were not consistently provided. The Activity Director confirmed the visits were not conducted as scheduled.
A resident experienced a decline in range of motion in both knees due to the facility's failure to provide necessary care. Initially, the resident had normal range of motion, but by July, contractures were observed. Staff interviews revealed that staffing shortages, particularly among aides, prevented them from completing assignments and providing essential care, such as range of motion exercises. The facility had previously discontinued a restorative program due to these staffing issues.
A facility failed to provide adequate staffing, affecting resident care. A resident with knee contractures did not receive necessary range of motion exercises, as confirmed by medical records and staff interviews. Staff reported consistent understaffing, particularly with aides, leading to incomplete care and the removal of the restorative aide position. Despite requests for agency staff, the facility operated below required staffing levels, impacting the quality of care provided.
A facility failed to accurately document a resident's dental condition during the admission assessment. The resident reported having only four teeth and difficulty chewing, but the clinical admission evaluation incorrectly marked 'own teeth' and left the dental section incomplete. The administrator confirmed the assessment's incompleteness.
Failure to Update Care Plan for Resident Behavioral Issues
Penalty
Summary
The facility failed to ensure that the care plan for Resident #48 was accurate and up to date, as required by regulations. Record review and staff interviews revealed that Resident #48 exhibited behaviors such as wandering into other residents' rooms, drinking from their cups, eating their food, and retrieving ice with bare hands, as well as public urination and using other residents' items. These behaviors were observed and documented by staff, but were not reflected in the resident's care plan. Staff interviews confirmed that the resident required ongoing re-queuing and redirection, and had difficulty adjusting to the facility, yet the care plan did not address these specific behavioral issues.
Failure to Provide Safe Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, as evidenced by multiple instances of blood pressure being taken in the resident's left arm, where an arteriovenous (AV) fistula was located. This practice is against professional standards as it can lead to serious complications such as clots, loss of use of the fistula, and potentially a stroke. The resident's medical records showed several documented instances where blood pressure was taken in the left arm, despite clear orders and care plans indicating that this should not occur. Additionally, the facility did not complete post-dialysis assessments for the resident upon their return from dialysis sessions. The dialysis communication book lacked documentation of these assessments, which are crucial for monitoring the resident's condition and ensuring any complications are promptly addressed. The care plan for the resident included instructions to monitor for signs of infection, edema, and bleeding upon return from dialysis, but these were not consistently followed. Observations revealed that there was no signage in the resident's room or on their person to alert staff about the restricted limb for blood pressure measurements. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the orders and care plan were not adhered to, leading to the deficiency. This oversight placed the resident at immediate risk of serious injury, prompting the state agency to determine the situation as an immediate jeopardy.
Removal Plan
- Resident #9 will be evaluated by the licensed nurse upon return to the facility.
- All dialysis residents have the potential to be affected.
- The Unit Managers/designee conducted an audit for all residents on dialysis with specific B/P orders to be taken and POST dialysis assessment is completed upon return to the facility with any corrective action immediately upon discovery.
- The Order for B/P not to be taken in the Left arm on Resident #9 will be added to the Medication Administration Record in all Capital letters and will be added to the care plan and kardex in capital letters.
- The Director of Nursing(DON)/designee will reeducate all nursing staff with a posttest to validate understanding regarding hemodialysis graft, fistula care, communication, and documentation.
- Verify orders and instructions from hemodialysis facility or hospital, if patient is a new Admission.
- Evaluate access site daily and on completion of hemodialysis (HD) or home hemodialysis (HHD) treatment. Observe for signs of complications.
- Inspect fistula site for decrease or absence of vein dilation.
- Palpate for distal thrill.
- Auscultate for bruit.
- Palpate skin around graft/fistula for warmth.
- Evaluate skin around vascular access noting redness, swelling, local warmth, exudate, tenderness.
- Observe for presence of fever, chills, hypotension and notify physician/advanced practice provider (APP) and hemodialysis facility staff for complications.
- Protect access site from getting wet for several hours after HD or HHD treatment.
- Avoid trauma or treatment procedures in the accessed extremity, such as limiting activity of extremity, blood pressure measurement, venipuncture, injection of any type, use of creams or lotions on the access site.
- Instruct patient to avoid excessive pressure on the extremity or strain and in strengthening exercises to enhance blood flow if permitted by physician/APP and dialysis facility.
- Document location of access site on admission assessment, status of access site in Nurses' notes, status of pulses distal to access area, color and temperature of extremity, presence or absence of pain or numbness, status of bruit and thrill, notification and response of physician/APP and dialysis facility, patient education and family involvement, nursing intervention.
- Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility.
- Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record, or the state required form and send with the patient to his/her HD facility visit.
- Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient.
- Upon return of the patient to the Center, a licensed nurse will review the certified dialysis facility communication, evaluate/observe the patient, and complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form.
- Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center.
- Document notification of certified dialysis facility regarding return of form or other communication.
- Maintain the Hemodialysis Communication Record or state required form in the patient's medical record.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work.
- New Licensed nurses will be provided education, including post-test during orientation by the DON/designee.
- Annual in-servicing will be provided to licensed nurses regarding medication administration.
- The DON/designee will complete medication pass competencies quarterly to ensure physician orders are followed including ensuring B/P's are not taken in restricted arm.
- The Unit Managers (UM)/Designee will conduct observations to ensure all licensed nurses are taking B/P and the licensed nurse is completing the dialysis communication sheets POST dialysis daily across all shifts.
- Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Abuse and Neglect Incidents in LTC Facility
Penalty
Summary
The facility failed to provide an environment free from abuse and neglect, as evidenced by two separate incidents involving residents. In the first incident, a Licensed Practical Nurse (LPN) physically abused a resident during an episode of combative behavior. The resident, who had a complex medical history including dementia and chronic kidney disease, became combative during incontinence care. The LPN, in an attempt to administer medication, was spat on by the resident and reacted by striking the resident in the face. This incident was witnessed by multiple staff members and was reported to the facility's administration. In the second incident, a Nurse Aide (NA) neglected a resident by leaving them in a soiled state. The resident was found with vomit on their clothing and dried feces on their legs, and their bed was soiled with urine and feces. The NA responsible for the resident's care admitted to not changing the resident, citing a concern about the resident becoming combative if awakened. This neglect was reported by another NA and confirmed by the LPN assigned to the resident that night. Both incidents were substantiated by the facility, with the staff members involved being terminated. However, the report notes that there was no evidence of education or other actions taken to prevent recurrence of the neglect incident, highlighting a gap in the facility's response to such deficiencies.
Medication Error: Insulin Administered to Non-Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving Resident #65. On April 19, 2024, Resident #65, who was not diabetic and had no insulin order, was mistakenly administered 25 units of insulin. This error occurred after a room change, where the resident was moved from room 401A to 107. The resident reported that the nurse did not verify the identity of the person receiving the insulin shot, leading to the administration of the wrong medication. The progress notes from the incident indicated that the resident's blood sugar was 135 before the insulin was administered, and after the error was discovered, the resident was understandably upset. The on-call doctor was notified, and initial orders were given to monitor the resident's blood sugar every 15 minutes. However, the resident initially refused to have his blood sugar checked, only consenting after speaking with his wife. Subsequent checks showed a blood sugar level of 118. Despite the seriousness of the error, the facility did not provide documentation of any investigation or process implementation to prevent such errors in the future. Interviews conducted during the investigation revealed that the LPN responsible for the error did not verify the resident's identity because they were unaware of the room change. The facility administrator confirmed that a one-to-one education session was conducted with the LPN involved, but this occurred two months after the incident. The LPN was noted to be a part-time or as-needed employee, which may have contributed to the oversight. The lack of immediate corrective action and investigation highlights a systemic issue within the facility's medication administration process.
Failure to Provide Showers and Timely Transfers
Penalty
Summary
The facility failed to provide showers and/or bed baths in accordance with the residents' preferences and/or their care plans. Several residents reported that staff preferred to give bed or sponge baths instead of showers, as it required less effort. This issue was identified for multiple residents, including those who had not received a shower for over thirty days, despite being scheduled for showers multiple times a week. The records showed inconsistencies in the provision of showers and bed baths, with significant gaps between bathing sessions. Resident #42 experienced psychosocial harm due to a delay in being transferred from her chair to her bed. During a night observation, the resident was found crying and repeatedly calling for help. Despite the presence of staff, the resident was not attended to promptly, leading to distress. The LPN on duty acknowledged the resident's agitation due to the delay and the need for assistance with a mechanical lift, which was not immediately available. Other residents, such as Resident #48, #40, and #3, expressed dissatisfaction with the lack of showers, which were important to them as per their Minimum Data Set (MDS) preferences. The facility's records corroborated these claims, showing a pattern of missed showers and infrequent bed baths. Interviews with residents and staff highlighted a systemic issue with the facility's ability to meet the residents' bathing preferences and schedules, contributing to the deficiency identified during the survey.
Infection Control Deficiencies in PPE Use and Waste Disposal
Penalty
Summary
The facility failed to maintain an appropriate infection control program, as evidenced by several observations and staff interviews. Soiled linen was found improperly disposed of, with linen observed on the PPE cart and on the floor in a resident's room. Staff, including a registered nurse and nurse aides, were observed not wearing proper personal protective equipment (PPE) while transferring and providing care to a resident in an Enhanced Barrier Precaution (EBP) room, despite signage indicating the required PPE for specific activities. Additionally, a meal tray that was refused by a resident was placed back onto a cart with clean trays, and uncovered bedpans were found on the floor in a restroom. Further observations revealed soiled gloves discarded on the floor of a hallway, which was confirmed by a licensed practical nurse as an infection control issue. Staff interviews indicated a lack of adherence to proper disposal protocols for soiled gloves and dressings, which should have been discarded in the appropriate receptacles within residents' rooms. These deficiencies in infection control practices had the potential to affect more than an isolated number of residents, given the facility's census of 71.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor residents' preferences for bed baths and showers, affecting five out of seven residents reviewed during the Long-Term Care Survey Process. Resident #60 expressed dissatisfaction with the infrequency of showers, having received only two showers between May and July 2024, despite being scheduled for twice-weekly showers. The Director of Nursing confirmed the lack of showers for Resident #60 since June 19, 2024. Similarly, Resident #63 reported not having a shower since early May 2024, although scheduled for twice-weekly showers, and the Director of Nursing acknowledged this issue. Resident #48 also reported that his requests for showers were not honored, with records showing he received no showers in January, February, and May 2024, and only two showers in June 2024. Despite expressing that choosing between different types of baths was very important to him, his preferences were not met. Resident #40, who indicated that choosing between bath types was somewhat important, received no showers from January to July 2024, with significant gaps between bed/sponge baths. Resident #3, who considered choosing between bath types very important, received only one shower in March and May 2024, and none in July 2024. The records revealed long periods without any form of bathing, such as a 17-day gap in March 2024. The Director of Nursing acknowledged the problem of not honoring residents' bathing preferences and stated that the facility was working on addressing the issue.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information. On July 23, 2024, at 11:04 PM, a Licensed Practical Nurse (LPN) was observed at the nurses' station using a computer. Shortly after, at 11:08 PM, a computer was found unattended on top of the medication cart with resident identifiable information visible on the screen. This situation presented a random opportunity for unauthorized access to sensitive information, potentially affecting more than a minimal number of residents in the facility, which had a census of 71 at the time. During an interview conducted at 11:12 PM, the LPN returned to the medication cart and locked the computer screen, acknowledging awareness that it had been left unlocked. The following day, the Director of Nursing (DON) confirmed in an interview that the computer and medication cart should have been secured to prevent such breaches of confidentiality.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for residents in several rooms, as observed during a facility tour. The tour revealed that multiple resident doors had visible cracks and rough edges with putty applied, indicating inadequate maintenance. Additionally, in one resident's room, the slats of the Packaged Terminal Air Conditioner (PTAC) unit were covered in a moldlike substance. The resident expressed concerns about allergies, which could be related to the mold. The Maintenance Supervisor confirmed the presence of mold and acknowledged the need for cleaning.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their medical and personal care needs. Resident #54's care plan did not include a diagnosis of Dementia, despite it being documented in their medical record. Similarly, Resident #61's care plan lacked interventions for their diagnosed anxiety disorder, even though the resident had been seen for psychological telemedicine visits. Resident #71's care plan was incomplete, missing focus areas such as activities of daily living, suspected infections, and risk for skin breakdown. These omissions were confirmed by the facility's Director of Nursing and Administrator during interviews. Additionally, the facility did not adequately address the personal hygiene preferences of several residents. Resident #51, #65, and #22 reported not receiving showers as per their preferences, with their care plans either lacking specific interventions or not being followed. Resident #9's care plan included an intervention to avoid taking blood pressure in the left arm due to an AV fistula, yet records showed this was not adhered to on multiple occasions. These failures were acknowledged by the facility's administration, indicating a systemic issue in care plan development and implementation.
Unsecured Treatment Cart and Medication in Resident Areas
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible, which had the potential to affect more than a limited number of residents. During an observation, an unlocked and unattended treatment cart was found in the resident TV room, making medication and treatment supplies accessible to residents, unauthorized persons, or visitors. This was confirmed by RN #21, who acknowledged that the treatment cart should not be left unlocked when unattended. Additionally, nystatin powder was found unsecured and unattended at a resident's bedside, allowing access to the medication by residents, unauthorized staff, or visitors. RN #21 confirmed that the medication should not be left out in the room and removed it upon discovery.
Failure to Conduct Yearly Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct yearly performance evaluations for three out of five Nurse Aides reviewed during the survey process. This deficiency was identified through a record review conducted at approximately 2:45 PM on 07/23/24, which revealed missing yearly performance evaluations for Nurse Aides #34, #63, and #61. The facility census at the time was 71. During a staff interview at approximately 3:30 PM on the same day, the Administrator confirmed the absence of these evaluations. The Administrator acknowledged awareness of the missing evaluations and stated that efforts were being made to catch up on them.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to conduct behavior and side effect monitoring for psychotropic medications for one of the five residents reviewed during the Long-Term Care Survey Process. Specifically, Resident #54 was prescribed Lorazepam Oral Tablet 0.5 MG for anxiety, with instructions to monitor for sedation, morning hangover, ataxia, nausea, and to report any side effects to the physician. However, a review of the Medication Administration Record (MAR) revealed that there was no monitoring conducted for the months of December 2023 through May 2024. During an interview, the Director of Nursing confirmed that behavior and side effect monitoring was not being performed.
Incomplete Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to maintain accurate temperature logs for the medication refrigerator, as observed during a survey on July 25, 2024. The survey revealed that the temperature recordings for the medication refrigerator were incomplete from March 2024 through July 2024. Specific dates were identified where the temperature checks were not documented, indicating a lapse in the facility's adherence to its policy of checking refrigerator temperatures twice daily. During the survey, the Administrator confirmed the incompleteness of the temperature logs. The facility's policy, titled 'Medication and Vaccine Refrigerator/Freezer Temperatures,' mandates that refrigerators and freezers used for storing medications and vaccines must operate within an acceptable temperature range and be checked twice daily. The failure to record these temperatures as per the policy could potentially affect more than a limited number of residents, given the facility's census of 71.
Expired Food Items Found in Kitchen
Penalty
Summary
The facility failed to ensure that food items were discarded after their expiration date, which had the potential to affect more than a limited number of residents. During an initial observation in the kitchen, scalloped potatoes were found wrapped in plastic wrap in the walk-in refrigerator with a discard date of 07/11/24, indicating they were out of date. Additionally, a box of onions in the walk-in refrigerator contained eight onions, four of which were covered in what appeared to be mold. During an interview, the Dietary Manager in Training (DMT) acknowledged that the potatoes were out of date and stated that they would dispose of the potatoes and onions. This deficiency was identified during a survey with a facility census of 71 residents.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that the resident call system was functioning as designed, which had the potential to affect more than a limited number of residents. During an observation tour of the 200 and 300 halls, it was found that the call light system was turned off at the end of the halls, and the volume was too low to be heard throughout the unit. The Maintenance Assistant verified that the system was turned off and stated that the staff had turned it off. The Maintenance Director confirmed that the call system was both visual and audible and noted that all the call systems in the building had been turned down since he started working there.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the State ombudsman of a discharge for a resident, identified as Resident #71. This deficiency was identified during a record review conducted on 07/23/24, which revealed that the resident had been discharged to another facility on 05/09/24. However, there was no evidence that the required notification of discharge was sent to the State ombudsman. During an interview on the same day, the Administrator confirmed the absence of the notification to the Ombudsman regarding the discharge.
Inaccurate MDS Discharge Destinations for Two Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments regarding the discharge destinations for two residents. For Resident #71, the record review revealed that the resident was discharged to another long-term care facility, but the MDS inaccurately listed the discharge destination as home. This discrepancy was confirmed by the Administrator. Similarly, for Resident #72, the record review showed that the resident was discharged to home, yet the MDS incorrectly recorded the discharge destination as a short-term general hospital. The Administrator also confirmed this error. These inaccuracies were identified during a record review and staff interview process.
Failure to Revise Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident when the status of her pressure ulcer changed. A record review revealed an order for the resident's right heel, which was initially documented as a Stage IV pressure ulcer requiring specific wound care. However, the care plan inaccurately listed the ulcer as a Stage 2 pressure ulcer. A subsequent skin and wound evaluation indicated that the pressure ulcer was unstageable, yet the care plan was not updated to reflect this change. During an interview, the Director of Nursing acknowledged the issue, stating that there were ongoing problems with care plan revisions.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an activity program that met the needs and interests of its residents, specifically for one resident identified in the report. Observations revealed that the resident spent extended periods sitting in the Television Lounge without engaging in meaningful activities. The resident's care plan emphasized the importance of engaging in daily routines that were meaningful and included scheduled one-to-one visits three times a week, which were not consistently provided. A review of the resident's activity participation records for several months showed a lack of consistent one-to-one visits and no participation in group activities. The Activity Director confirmed that the scheduled one-to-one visits were not being conducted as planned. This deficiency highlights the facility's failure to adhere to the resident's care plan and provide the necessary engagement opportunities to meet the resident's preferences and needs.
Failure to Prevent Reduction in Range of Motion Due to Staffing Shortages
Penalty
Summary
The facility failed to provide necessary services and treatment to a resident to prevent a reduction in range of motion. Resident #64, who initially had normal range of motion in the lower extremities as per evaluations and records from March and April 2024, was observed to have contractures in both knees by July 2024. The resident reported not receiving assistance with range of motion exercises during care, and the medical records indicated a decline in range of motion by June 2024. Interviews with staff, including nurse aides and registered nurses, revealed that the facility was experiencing staffing shortages, particularly among aides. This shortage resulted in insufficient time to complete assignments and provide necessary care, such as range of motion exercises. The facility previously had a restorative program to address such needs, but it was discontinued due to staffing issues, contributing to the deficiency in care for Resident #64.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by the experiences of a resident and multiple staff members. A resident, identified as having contractures in both knees, reported not receiving assistance with range of motion exercises, which were previously within normal limits according to medical records. The resident's condition deteriorated without the necessary care, highlighting the facility's inability to maintain adequate staffing levels to ensure proper resident care. Interviews with nurse aides and registered nurses confirmed that the facility was consistently understaffed, particularly with aides, leading to incomplete care assignments and the removal of the restorative aide position. Staff interviews revealed that the facility typically operated with fewer aides than required, particularly during the day shift, and that weekends were often worse. Aides reported being asked to work extra hours frequently due to staffing shortages, which affected their ability to provide comprehensive care, such as assisting with range of motion exercises and ensuring residents received showers. Despite repeated requests for agency staff to alleviate the situation, these requests were not fulfilled, and management reportedly deflected responsibility onto the staff. The administrator acknowledged the need for more aides but confirmed that the facility often operated below the necessary staffing levels.
Incomplete Dental Assessment Documentation
Penalty
Summary
The facility failed to accurately document the dental condition of a resident during the admission assessment. During an interview, the resident stated that they only have four teeth and have difficulty chewing food. However, a review of the resident's clinical admission evaluation revealed that the section regarding dental condition was incomplete, with the box indicating 'own teeth' marked incorrectly. The administrator confirmed the incompleteness of the dental assessment upon review.
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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