Sistersville Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sistersville, West Virginia.
- Location
- 201 Wood Street, Sistersville, West Virginia 26175
- CMS Provider Number
- 515131
- Inspections on file
- 18
- Latest survey
- April 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sistersville Center during CMS and state inspections, most recent first.
Surveyors found that garbage and refuse, including gloves, food, and disposable items, were scattered around two dumpsters, with one dumpster having both lids open and the other having a broken lid. The Facility Administrator confirmed these observations.
The facility did not ensure the required QAPI team members, including the DON, were present, and failed to hold quarterly QAPI meetings for several months. This was confirmed through record review and staff interviews.
Multiple residents experienced undignified dining conditions, including being left unseated or unserved while others ate, having clothing protectors placed without consent, and waiting extended periods for meal service or feeding assistance. Staff were observed standing while feeding, and meal trays were distributed inconsistently, contrary to facility policy.
A resident developed a blister on her right heel, and although a nurse practitioner assessed the wound and new treatment orders were initiated with the POA notified, staff did not complete a required change in condition (CIC) assessment. The DON confirmed the absence of CIC documentation for this new pressure ulcer.
Multiple residents did not receive care in accordance with their individualized care plans, including failures to honor dietary restrictions, incomplete documentation of meal intake, and lack of implementation of interventions for emotional distress. Additionally, care plans for several residents did not address all medical diagnoses, and required monitoring for medication side effects and behaviors was not consistently documented, as confirmed by the DON and administrator.
Surveyors found that care plans were not updated for several residents after significant changes in their health status or care needs. For example, a resident who suffered fractures after a fall did not have this reflected in their care plan, another who required feeding assistance was still listed as needing only set-up help, and a resident with a change in code status to DNR still had a care plan indicating full code. Other issues included care plans referencing hospice services for a resident not on hospice and instructions to encourage oral fluids for a resident who was NPO. The DON confirmed these discrepancies during interviews.
Surveyors found that physician orders for medication administration, behavioral and pain monitoring, and specific treatments were not consistently followed for multiple residents. Medications were often administered late, and required documentation for treatments and monitoring was missing. Staffing levels contributed to these deficiencies, with only two nurses covering high-acuity areas, resulting in incomplete care and failure to adhere to prescribed orders.
On two consecutive days, the facility did not provide enough nursing staff on one hall, leaving a single nurse responsible for 42 residents. This resulted in multiple medications and treatments being administered late or not at all, as confirmed by staff interviews and documentation review. The DON acknowledged that physician orders for medications and treatments were not followed due to the staffing shortage.
Staff did not follow the approved daily menus, serving BBQ pork on sandwich bread instead of a roll and omitting lettuce and tomato garnish from a fish filet meal. One resident had difficulty eating the BBQ on the bread provided. The Corporate Dietary Manager confirmed the deviations were due to supply and temperature concerns.
The facility did not ensure that food was served at safe and appetizing temperatures, with cold items such as lettuce and tomatoes held above 41°F and hot items like a fish sandwich and potato wedges served below 135°F. No substitute was provided when cold vegetables were withheld due to improper temperatures.
Multiple food items, including frozen meats, bread, produce, and resident snacks, were found opened and not labeled or dated as required. Staff confirmed these deficiencies, and unsanitary conditions were observed in food preparation areas, including a dirty handwashing sink and dried food on kitchen equipment.
Surveyors identified incomplete, inaccurate, and untimely medical record documentation, including missing medication dosages in physician orders, undated POST forms, lapses in required behavioral monitoring documentation for two residents with psychiatric diagnoses, and delayed therapy documentation. Staff interviews confirmed these documentation issues.
Surveyors identified multiple failures in the infection prevention and control program, including incorrect placement of Enhanced Barrier Precautions (EBP) signage for two residents, failure by a nurse to use required PPE during a dressing and incontinence care, and lack of resident hand hygiene before meals in the dining room. These deficiencies were observed among residents with indwelling devices and wounds, and staff acknowledged the lapses during interviews.
A resident with hemiplegia and hemiparesis was unable to reach the call light due to limited range of motion, resulting in the resident being unable to request assistance without help from a surveyor. Staff confirmed the resident uses the call light when it is within reach and noted that a specialized call light was previously used but not available at the time.
Staff did not follow facility policy during meal service by leaving food on a tray for a resident and leaving another resident's tray on the table beside their meal, resulting in a failure to provide a home-like dining environment.
A resident experienced significant weight loss over a 30-day period, but the MDS assessment inaccurately recorded the weight loss status as 'no or unknown.' The DON confirmed the error in the MDS documentation.
A resident developed a pressure ulcer on the right heel that was not prevented by facility staff. The wound was identified as a blister and assessed by a nurse practitioner, who ordered treatment. The DON confirmed the development of the pressure ulcer during record review and interview.
A Maintenance Director was observed transporting four oxygen tanks without a carrier, holding two in each hand and allowing them to clank together. The Maintenance Director admitted knowing this was not the proper method but stated he was helping the oxygen delivery person. The Corporate RN confirmed that oxygen tanks should not be moved without a carrier.
A resident's MPOA provided consent for a pneumococcal vaccination, but review of the MARs showed no documentation that the vaccine was administered. The DON confirmed there was no evidence the resident received the immunization after consent was given.
Improper Disposal of Garbage and Refuse at Dumpster Area
Penalty
Summary
Surveyors observed that garbage and refuse were not properly disposed of at the facility. Specifically, two dumpsters located behind a wooden fence were found with various items such as gloves, food, cup lids, straws, plastic forks, and boxes scattered around them. Additionally, both lids on one dumpster were open and laid back, while the other dumpster had a broken lid that was completely detached. These conditions were confirmed during an interview with the Facility Administrator, who acknowledged the state of the dumpsters. The facility census at the time was 65 residents. No information was provided regarding the medical history or condition of any specific residents affected by this deficiency.
Failure to Maintain Required QAPI Membership and Quarterly Meetings
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance and Performance Improvement (QAPI) team were present and that quarterly meetings were held as mandated. Record review showed that the Director of Nursing (DON) position was vacant from 02/19/24 through 04/08/24, with no individual filling in for the DON during this period, resulting in the absence of a required QAPI team member. Additionally, sign-in sheets confirmed that no QAPI meetings took place in January, February, or March of 2025. These findings were verified through interviews with the Administrator and the current DON.
Failure to Provide Dignified Dining Experience During Meal Service
Penalty
Summary
The facility failed to provide a dignified dining experience for residents, as evidenced by multiple observations during meal service. Residents were not seated at the same time, and meals did not arrive simultaneously for those at the same table. Several residents were left seated in the center of the dining room while others were served, and clothing protectors were placed on residents without asking for their preference. One resident attempted to feed another, requiring staff intervention, and some residents experienced significant delays in receiving their meals or assistance with feeding. For example, one resident waited over 30 minutes to be fed after their tablemates had already begun eating, and another resident's tray was placed out of reach for an extended period before being fed. Additional observations included a resident who was tearful throughout the meal, with her hands covered by a clothing protector, and who waited 11 minutes before receiving assistance with eating. Staff were observed standing while feeding residents, and some residents waited several minutes longer than their tablemates to receive their food. The facility's policy stated that meals should be served table by table, but this was not followed, and dietary staff loaded trays onto carts randomly rather than by room or table order.
Failure to Complete Change in Condition Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to complete a change in condition (CIC) assessment for a resident who developed a blister on her right heel. According to the progress note, the resident was seen by a nurse practitioner who ordered Sure Prep to be applied to the right heel twice daily, and the resident's power of attorney was notified and agreed with the order. However, upon review of the records, there was no documentation of a CIC being completed for this new pressure ulcer. The Director of Nursing confirmed during an interview that the resident had a blister on her right heel and that no CIC had been completed.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, resulting in unmet needs and lack of adherence to prescribed interventions. For one resident, staff did not follow a documented dietary restriction for pork, as evidenced by the resident being served and fed pork despite clear instructions on the lunch ticket and care plan. Additionally, meal intake documentation was incomplete for several days, and interventions for emotional distress, such as providing a huggable doll or preferred television programming, were not implemented when the resident was observed to be tearful. Another resident's care plan interventions for monitoring medication side effects, behaviors, pain assessments, and anticoagulation therapy were not carried out, as shown by missing documentation on the Medication Administration Record (MAR) for multiple shifts. Similar failures were observed for two other residents, whose care plans did not address all of their medical diagnoses, including conditions such as malnutrition, dysphagia, hypertension, hyperlipidemia, osteoporosis, anemia, muscle weakness, and muscle spasms. The Director of Nursing confirmed these omissions in the care plans. For two additional residents with complex psychiatric and neurological diagnoses, the care plans included interventions to monitor for medication side effects and specific behavioral symptoms as ordered by physicians. However, the MARs showed multiple instances where required monitoring and documentation of behaviors were not completed across several months. The facility administrator acknowledged the issues with documentation and care plan implementation during an interview.
Failure to Revise Care Plans Following Changes in Resident Status
Penalty
Summary
The facility failed to ensure that care plans were revised in a timely and accurate manner for multiple residents following significant changes in their conditions or care needs. For one resident who experienced a fall resulting in fractures, the care plan was not updated to reflect the actual fall with injury, despite ongoing pain and diagnostic findings. Another resident, who required assistance with eating, was observed being fed by staff, yet the care plan continued to state only set-up assistance was needed. A third resident, previously using a walker, was observed ambulating independently with a bent gait due to Parkinson's disease, but the care plan still included supervision with a walker. The DON confirmed that these care plans had not been revised to reflect the residents' current statuses. Additional deficiencies included a resident whose code status had changed to Do Not Resuscitate (DNR) with comfort-focused treatment, but the care plan still indicated full code status. Another resident, who was NPO and receiving enteral feeding, had a care plan that incorrectly stated encouragement of oral fluid intake and no artificial nutrition desired. Lastly, a resident's care plan referenced hospice services and interventions, despite no hospice order or services being in place, and the DON confirmed no residents were receiving hospice care at the time. These findings were based on record reviews, staff interviews, and direct observations, affecting more than a limited number of residents in the facility.
Failure to Follow Physician Orders and Timely Medication Administration
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to follow physician orders for several residents. Record reviews and staff interviews revealed that medication administration, behavioral monitoring, pain assessments, and specific treatment orders were not consistently completed as prescribed. For example, several residents did not receive required monitoring for behaviors, pain, and medication side effects on numerous shifts across multiple months, as documented in their Medication Administration Records (MARs). Additionally, dietary restrictions were not adhered to, such as a resident with a physician order for no pork being observed consuming pork. Further deficiencies were noted in the timeliness of medication administration. On specific dates, numerous medications were administered late, sometimes by nearly two hours, affecting a significant number of residents. The report details instances where medications for chronic conditions, such as antihypertensives, anticoagulants, and antipsychotics, were not given within the ordered timeframes. The facility's nurse staffing schedule showed only two nurses on duty for a high-acuity unit, which contributed to the delays and incomplete treatments. Treatment orders for wound care, skin care, and enteral feeding site care were also not followed, with documentation missing for required interventions on several residents. These lapses included failure to apply prescribed creams, cleanse wounds, and monitor surgical sites as ordered. The Director of Nursing confirmed these omissions during interviews, and the documentation reviewed supported the findings of incomplete or missed care as per physician directives.
Failure to Provide Sufficient Nurse Staffing Resulting in Delayed Medications and Missed Treatments
Penalty
Summary
The facility failed to provide sufficient nursing staff on the B hall during two consecutive days, resulting in one nurse being responsible for 42 residents during the day shift. The daily staff postings and nurse schedules confirmed that only two nurses were scheduled for both the red and blue halls, with no additional nurse coverage for the blue hall, despite its higher resident census and acuity. Staff interviews corroborated that coverage was not obtained for a call-in, and the nurse assigned to the blue hall reported being responsible for all 42 residents, which impacted the ability to complete required tasks. As a result of the insufficient staffing, multiple medications were administered late to several residents, with delays ranging from over an hour to more than two hours past the scheduled administration times. The report lists numerous instances where medications such as Neurontin, Midodrine, Losartan, Duloxetine, and others were given significantly later than ordered. Additionally, enteral feedings and other time-sensitive treatments were also delayed. The daily nursing hours per patient day were above the minimum, but the higher acuity of residents and the lack of adequate nurse coverage contributed to the delays. Furthermore, the facility failed to follow physician orders for resident treatments on both days in question. Documentation was missing for a wide range of required treatments, including wound care, application of creams, cleansing of surgical sites, and monitoring for signs of infection. The DON confirmed that these treatments and medication administrations were not completed as ordered, and was unable to provide an explanation for the staffing shortfall on those days. The lack of sufficient and competent nurse staffing directly led to incomplete care and failure to meet residents' needs as required.
Failure to Follow Approved Menus for Resident Meals
Penalty
Summary
The facility failed to follow the daily menus as planned and approved, resulting in deviations from the prescribed meals for residents. On one occasion, BBQ pork was served on white sandwich bread instead of the menu-specified roll, affecting at least three residents on regular diets. One resident experienced difficulty picking up and eating the BBQ on the light bread provided. The Corporate Dietary Manager confirmed that no buns or rolls were available and attributed this to a delivery issue. On another occasion, the menu called for a breaded fish filet on a roll with lettuce and tomato garnish, but the garnish was not served due to concerns about serving temperatures.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to prepare and serve food at safe and appetizing temperatures, as required by its own policy and procedures. During a lunch meal observation, cold food items such as lettuce, shredded lettuce, and tomatoes were found to be held at temperatures above the required maximum of 41°F, with readings between 45.2°F and 52.9°F. These items were subsequently placed in the refrigerator or freezer to cool, but still did not reach appropriate temperatures before the end of the observation period and were not served; no substitute vegetable was provided. Additionally, a test tray delivered to a resident area showed that hot food items, including a fish sandwich and potato wedges, were served at temperatures below the required minimum of 135°F, with readings of 127.7°F and 113.1°F, respectively. These findings were confirmed by the Corporate Dietary Manager and observed by the state surveyor.
Improper Food Storage, Labeling, and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper storage and labeling of food items and cleanliness of food preparation equipment, as required by their own policies and professional standards. During an inspection, multiple food items were found opened and not labeled or dated, including frozen chicken breast, Imperial Beef Base, celery, lettuce, sandwich bread, and a can of Dr. Pepper. Additionally, resident snacks such as sherbet, fortified pudding, applesauce, and thickened water were found opened without date ranges or use-by dates in various pantries. These findings were confirmed by facility staff, including the Corporate Dietary Manager, the Memory Support Director, and an LPN, who acknowledged the lack of proper labeling and dating. Further observations revealed unsanitary conditions in food preparation and serving areas. The handwashing sink behind the dining room serving center contained a brown substance in the sink bowl and lacked a trash can for disposal of paper towels or garbage. Dried food was also observed on the outside of the kitchen refrigerator. These lapses in food storage, labeling, and cleanliness had the potential to affect more than a limited number of residents, as noted in the facility census.
Incomplete and Untimely Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and timely medical records for several residents, as evidenced by multiple documentation lapses. For one resident, an LPN administered Zyrtec without a specified dosage in the physician's order, and the Director of Nursing confirmed the omission, noting that the pharmacy only supplies one dosage but the order itself was incomplete. Another resident's Physician Orders for Scope of Treatment (POST) form was found to be missing a date next to the resident's signature, which was acknowledged by the Director of Nursing. Two residents with complex psychiatric and behavioral diagnoses had care plans and medication administration records that required daily monitoring and documentation of specific behaviors. However, reviews of their MARs revealed multiple instances where required behavior monitoring was not documented across several shifts in January, February, and March. The facility administrator confirmed issues with documentation and care plans during an interview. Additionally, therapy documentation for another resident was not completed in a timely manner, with several speech therapy notes and evaluations being signed or entered days after the date of service. The speech therapist acknowledged the delays, attributing them to system access issues and personal workflow, but confirmed that documentation was sometimes late. These findings collectively demonstrate a pattern of incomplete, inaccurate, or untimely medical recordkeeping affecting multiple residents.
Infection Control Program Deficiencies and Lapses in Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. For one resident with an indwelling urinary catheter and a pressure ulcer dressing, Enhanced Barrier Precautions (EBP) signage was incorrectly placed outside the room, indicating the wrong resident required EBP. Both the resident and her roommate required EBP, but the signage did not accurately reflect this, as confirmed by the Director of Nursing. Additionally, a nurse failed to follow EBP protocols during a dressing and incontinence brief change for another resident, neglecting to wear a gown as required, despite signage indicating both residents in the room were on EBP. The facility also did not provide hand hygiene for residents before meals in the main dining room, contrary to its own policy. During a meal observation, no hand hygiene was performed for any residents, and staff acknowledged that this step should have been completed. These lapses in infection control practices had the potential to affect more than a limited number of residents, given the facility's census and the nature of the observed deficiencies.
Failure to Ensure Call Light Accessibility for Resident with Limited Mobility
Penalty
Summary
A resident with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side was observed sitting upright in bed, leaning toward the left, and unable to reposition himself. The resident attempted to use the call light to request assistance but was unable to reach it due to limited range of motion. During the observation, the state surveyor had to activate the call light on the resident's behalf at the resident's request. Staff interviews confirmed that the resident typically uses the call light when it is accessible, and it was noted that the resident previously had a pancake call light, which was not in use at the time of the observation.
Failure to Provide Home-like Dining Environment
Penalty
Summary
The facility failed to provide a home-like dining environment for its residents, as observed during a lunch meal. Staff did not follow the facility's policy and procedure, which requires all items to be removed from trays, packages to be opened, and lids to be removed before serving meals to residents. Specifically, staff left a resident's food on their tray during the lunch meal, and another resident's tray was left on the table beside their meal while they ate. These actions did not align with the facility's stated procedures for meal service and affected the dining experience for more than a limited number of residents.
Inaccurate MDS Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment regarding weight loss for one resident receiving tube feeding. Record review showed that the resident experienced a significant weight loss of 5.43% over 30 days, with weights documented as 176.8 pounds and 167.2 pounds on two separate dates. However, the MDS significant change assessment completed shortly after this period incorrectly indicated 'no or unknown' for the question regarding a loss of 5% or more in the last month. The Director of Nursing (DON) later confirmed that the MDS was inaccurate in reporting the resident's significant weight loss.
Failure to Prevent Development of Pressure Ulcer on Resident's Heel
Penalty
Summary
A review of records and staff interviews revealed that the facility failed to prevent the development of an avoidable pressure ulcer on the right heel of one resident. Documentation showed that the resident developed a blister on the right heel, which was identified and assessed by a nurse practitioner, resulting in a new treatment order. The Director of Nursing confirmed the presence of the pressure ulcer. This deficiency was identified during the review of three records under the care area of pressure ulcers, with the facility census at 65 residents. The findings indicate that the pressure ulcer was not prevented, and the development of the wound was confirmed through both documentation and staff acknowledgment. No information was provided regarding the resident's prior medical history or specific risk factors for pressure ulcer development at the time of the deficiency.
Unsafe Transport of Oxygen Tanks by Maintenance Director
Penalty
Summary
During an observation, the Maintenance Director was seen carrying four oxygen tanks without using a carrier, holding two tanks in each hand as he walked around the building. The tanks were clanking together during transport. When interviewed, the Maintenance Director acknowledged awareness that this was not the correct procedure, explaining that he was attempting to assist the oxygen delivery person, who was tired. The Corporate RN confirmed that oxygen tanks should not be transported without a carrier. No residents were directly involved or affected at the time of the observation, and no specific patient medical history or condition was mentioned in relation to the deficiency.
Failure to Administer Pneumococcal Vaccine After Consent Obtained
Penalty
Summary
The facility failed to provide pneumococcal immunization according to its own policy and standards of practice for one resident. The policy required obtaining consent from the patient or representative and administering the vaccine. In this case, the resident's Medical Power of Attorney (MPOA) provided consent for the pneumococcal vaccination, as documented in the electronic health record. However, a review of the Medication Administration Records (MARs) for the relevant months showed no documentation that the vaccine was administered. The Director of Nursing (DON) confirmed that there was no evidence the resident received the vaccination after consent was obtained.
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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