Summers Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hinton, West Virginia.
- Location
- 198 John Cook Nursing Home Road, Hinton, West Virginia 25951
- CMS Provider Number
- 515170
- Inspections on file
- 21
- Latest survey
- August 20, 2025
- Citations (last 12 mo.)
- 27 (1 serious)
Citation history
Health deficiencies cited at Summers Healthcare Center during CMS and state inspections, most recent first.
Multiple residents experienced harm due to the facility's failure to recognize and treat changes in condition, follow physician orders for medication administration and monitoring, and ensure dietary safety. Errors included missed side effect monitoring, improper medication administration, lack of documentation, and failure to protect a resident with an NPO order from receiving food, resulting in hospitalization and death.
Staff failed to properly assess, monitor, and treat pain for three residents, including not providing ordered interventions, not notifying the physician of uncontrolled pain, not investigating the cause of increased pain that was later found to be due to fractures, and not ensuring timely pain relief when a prescribed medication was unavailable. These failures resulted in actual harm and were confirmed through record review and interviews.
The facility did not provide a dignified dining experience by serving meals with plastic silverware to most residents due to a shortage of clean utensils. Additionally, a nurse aide entered a resident's room without knocking or announcing, contrary to facility policy, resulting in a failure to maintain resident privacy and dignity.
The facility did not consistently follow posted menus or provide residents with the foods they ordered, resulting in menu substitutions, missing items, and meals not prepared according to recipes. A resident did not receive the double fruit portions or ice cream indicated on his tray ticket, and staff confirmed shortages of key menu items and improper meal preparation.
Surveyors identified that several residents consistently received food that was cold, tough, and did not match the posted menu or their dietary orders. Staff interviews revealed a lack of adherence to recipes and menu planning, and test trays showed food items not prepared as required, with some served below safe temperatures. Residents also reported not receiving alternate menu options and insufficient portions.
A resident with orders for both breakfast and lunch to be sent on dialysis days did not consistently receive both meals, with staff confirming only one meal was typically provided. Additionally, meal service times were inconsistent, and some meal components were missing or delayed, failing to meet residents' needs and preferences.
Surveyors found that staff failed to properly store and label multiple opened food items, including thickened liquids, bread, ice cream, and condiments, in both the kitchen and nourishment pantries. Several items were not sealed, not dated, or lacked use-by dates, contrary to facility policy and professional standards. These practices were confirmed by dietary management and LPNs during the investigation.
Staff failed to follow infection control protocols, including proper hand hygiene and use of PPE, for two residents on transmission-based precautions. An LPN did not perform hand hygiene between glove changes during dressing changes and incontinence care for a resident with ESBL, and a nursing assistant was unaware of updated isolation status. For another resident with C. diff, a nursing assistant entered the room without PPE and used hand sanitizer instead of soap and water after contact, contrary to facility policy.
The facility did not retain required documentation showing that residents or their representatives were educated about and either accepted or refused influenza and pneumococcal vaccines. Immunization reports indicated that some residents received or refused vaccines, but consent or declination forms were missing from their records, as confirmed by the DON.
The facility did not ensure that food service areas and resident rooms were free from flies, as evidenced by flies observed in the kitchen and dishwasher areas and reports from two residents who experienced ongoing fly issues in their rooms. Staff confirmed the presence of flies, and the administrator stated there was no specific pest control policy in place.
A deficiency was cited when a resident's care plan did not include all required elements, such as measurable timetables and specific actions, resulting in incomplete planning and documentation for the resident's care.
A resident on a Dysphagia Mechanical Soft diet was served regular-texture foods, including uncut spaghetti and improperly prepared zucchini, which did not meet dietary requirements. Staff failed to follow prescribed recipes and diet guidelines, resulting in the resident being unable to eat the meal provided.
Three residents did not receive meals in accordance with their documented allergies, intolerances, or preferences. One did not receive a prescribed nutritional supplement, another with a fish allergy was denied alternate menu options due to unavailable lunch meat, and a third who disliked pork was served a ham-based meal after menu substitutions. Staff confirmed food shortages and substitutions due to missed orders and staffing issues.
Failure to Provide Necessary Care, Medication Administration, and Dietary Safety
Penalty
Summary
The facility failed to provide necessary care and services by not recognizing and treating changes in condition, not following physician orders for medication parameters, failing to document medication administration, and not ensuring food was provided in the correct form. Multiple residents experienced harm as a result, including one resident who was hospitalized with respiratory failure, urinary tract infection, and aspiration pneumonia after staff failed to assess and notify a physician about abnormal urinary output and repeated episodes of distress. Another resident died after being given food despite an order for nothing by mouth (NPO), with the facility failing to protect the resident from others providing food. Medication administration errors were identified for several residents. Orders for side effect monitoring of psychotropic medications were not completed on multiple occasions, and insulin was held without a physician order. Residents received medications such as Midodrine and gabapentin outside of prescribed parameters, including administration when blood pressure was above the hold threshold and dispensing more doses than ordered. Documentation was lacking for medication and treatment administration, and in some cases, there was no evidence that required monitoring or physician notification occurred after abnormal findings. The facility also failed to ensure that residents' dietary needs were met according to orders. One resident did not receive prescribed hemorrhoid cream, with no documentation to support administration. Another resident with a profound swallowing disorder and NPO order died after choking on food, with the investigation failing to determine how the food was provided and no follow-up education for staff or residents with modified diets. These deficiencies were confirmed through record review, interviews, and observations, and were acknowledged by the Director of Nursing.
Failure to Assess, Monitor, and Treat Pain According to Standards
Penalty
Summary
The facility failed to assess, monitor, and treat pain in accordance with professional standards for three residents, resulting in actual harm. For one resident, nursing staff documented multiple instances of moderate to severe pain over several months but did not provide either non-pharmacological or pharmacological interventions as ordered by the physician. The nurse also failed to assess the pain for location or duration and did not notify the physician of the resident's increased pain, despite clear orders to do so when pain was not controlled or was new in onset. Another resident experienced an increase in pain upon movement and transfers. Although pain medication was administered and later increased, staff did not assess the underlying cause of the pain, which was subsequently found to be due to two fractures. In a separate case, a resident reported numbness and tingling at an amputation site, which was communicated to the physician. The physician indicated the issue would be addressed the following day, but there was no documentation that the resident was evaluated or that treatment was prescribed, and the resident continued to experience symptoms. Additionally, for a resident who was prescribed a new pain medication, staff failed to notify the physician when the ordered medication was unavailable and did not obtain an alternative order, despite the availability of a substitute medication. This resulted in the resident not receiving pain relief in the hours prior to death. These failures were confirmed through record review, staff interviews, and resident interviews, and affected three of eight sampled residents reviewed for pain management.
Failure to Ensure Resident Dignity During Meals and Room Entry
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents by providing plastic silverware during meals. On two separate occasions, the majority of residents in the main dining room and residents on the last halls were served meals with plastic utensils due to a shortage of clean regular silverware. Staff interviews confirmed that the kitchen had run out of clean silverware, and the issue persisted until it was brought to the attention of staff by the state surveyor. The use of plastic silverware was observed and acknowledged by multiple staff members, indicating a lapse in maintaining resident dignity during meal service. Additionally, the facility did not follow its own policy regarding resident privacy and dignity when a nurse aide entered a resident's room without knocking or announcing themselves. The incident was observed by a state surveyor and confirmed by the unit manager, who acknowledged that the staff member should have knocked before entering. The facility's written policy requires staff to knock and wait for an answer before entering a resident's room, but this procedure was not followed, resulting in a failure to ensure resident privacy and dignity.
Failure to Follow Menus and Provide Ordered Foods
Penalty
Summary
The facility failed to ensure that menus were followed and that residents received the foods they wanted or ordered, as required. On multiple occasions, the kitchen ran out of key menu items, such as lunch meats and chicken tenders, resulting in substitutions that were not consistent with the posted menus. Staff confirmed that certain items listed as 'Always Available' were not in stock for several days, and that menu substitutions were made without following proper recipes or procedures. For example, zucchini was served boiled and without the required ingredients, rather than being prepared according to the facility's recipe, which called for baking with olive oil, pepper, parmesan cheese, and garlic. Staff also indicated a lack of awareness regarding the existence of recipes for menu items. A resident reported dissatisfaction with the food and was observed receiving a meal that did not match the tray ticket instructions. The resident, who was supposed to receive double fruit portions and vanilla ice cream, instead received only one fruit cup and no ice cream. The resident expressed a preference for fruit and ice cream and stated he would have eaten them if provided. The administrator confirmed that the resident had not received the correct portions as indicated on the tray ticket. These failures demonstrate that the facility did not consistently provide meals as planned or as ordered by residents, affecting the nutritional adequacy and resident choice in meal service.
Failure to Provide Palatable, Properly Prepared, and Appropriately Tempered Food
Penalty
Summary
Surveyors found that the facility failed to ensure food was prepared and served in a manner that conserved nutritive value, flavor, and appearance, and did not consistently provide food that was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported that their food was often cold, tough, and did not match the menu or their dietary tickets. One resident stated that the food was always ice cold and not as described on the menu, while another reported not receiving the ordered food due to issues in the kitchen. Residents also indicated that food was left in the hallway before delivery, contributing to it being served cold. During a test tray observation, surveyors noted that the zucchini was not prepared according to the provided recipe, as it was boiled instead of baked, lacked parmesan, and was described as bitter, tough, and rubbery. Staff interviews revealed that recipes and menus were not consistently followed, and some staff were unaware of the existence of recipes. Temperature checks of trays showed food items being served below recommended temperatures. Additionally, residents reported not receiving alternate menu options and insufficient portions, with one resident specifically noting that their breakfast order was not consistently fulfilled.
Failure to Provide Timely and Appropriate Meals for Dialysis Resident
Penalty
Summary
The facility failed to ensure that meals were provided at regular times and did not consistently provide required meals to a resident on dialysis. Specifically, a resident with a physician's order for bagged breakfast and lunch to be sent with him on dialysis days reported that the facility did not consistently send lunch, and sometimes an aide would make one, but this was infrequent. Staff interviews confirmed that only one meal, lunch, was typically sent, and not both breakfast and lunch as ordered. The Treatment Administration Record was initialed to indicate a lunch was sent, but there was no confirmation that both meals were provided as required. Additionally, observations and staff interviews revealed inconsistencies in meal service times, with lunch trays being delivered and served outside of the scheduled meal times. There were also issues with meal components, such as not having enough pears for trays, which were to be sent out later. These practices failed to ensure that meals and snacks were served in accordance with residents' needs, preferences, and requests, and did not meet the requirements for providing suitable and nourishing alternatives for residents who needed to eat at non-traditional times.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as evidenced by multiple instances of improper food storage and labeling. During a review of facility policies, it was noted that opened food items are required to be dated and stored properly, with specific instructions for dry, refrigerated, and frozen foods. However, observations in the kitchen and nourishment pantries revealed several opened food items, such as thickened liquids, spaghetti, pancake syrup, frozen green beans, chicken pot pie mix, bread, coffee, ice cream, relish, ranch dressing, and nutritional supplements, that were either not sealed, not labeled, or lacked use-by dates. Staff interviews confirmed that these items were not managed according to the facility's own policies, with some items being immediately discarded upon discovery. The deficiency was identified through record review, staff interviews, and direct observation, and it was confirmed by both the Regional Dietary Manager and LPNs responsible for monitoring food storage. The facility census at the time was 102, and the improper storage practices had the potential to affect more than a limited number of residents. No specific residents were identified as being directly affected at the time of the survey, and there were no details provided regarding the medical history or condition of any residents in relation to the deficiency.
Failure to Follow Infection Control Protocols and Transmission-Based Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in following transmission-based precautions and proper hand hygiene protocols. For one resident with pressure ulcers and an ESBL urinary tract infection, an LPN performed dressing changes and incontinence care without performing hand hygiene between glove changes, despite facility policy requiring hand hygiene when moving between contaminated and clean body sites. The LPN acknowledged not performing hand hygiene during these procedures. Additionally, a nursing assistant was observed feeding the same resident in their room without wearing required personal protective equipment (PPE), such as a gown and gloves, and was unaware of the resident's updated contact isolation status. Another resident, under contact isolation and enteric precautions for C. difficile, was also not provided appropriate infection control measures. A nursing assistant entered the resident's room to deliver and set up a meal tray without donning a gown or gloves, touched the resident and their environment, and upon leaving, used hand sanitizer instead of washing hands with soap and water as required for C. difficile precautions. The nursing assistant believed the precautions only applied to direct care, not tray delivery. The Director of Nursing confirmed that contact enteric precautions applied to all staff entering the room.
Lack of Documentation for Flu and Pneumonia Vaccine Consents
Penalty
Summary
The facility failed to provide and document influenza and pneumococcal vaccinations according to accepted standards of practice. Specifically, the facility did not retain documentation that residents or their representatives received education regarding the vaccines, nor did it retain records indicating whether the vaccines were accepted or refused. This deficiency was identified through record review and staff interview, affecting three out of five residents reviewed for immunizations. The facility's policy required that residents or their representatives complete consent or declination forms for these vaccines, but these forms were missing from the medical records. For the residents involved, immunization reports indicated that some received the influenza vaccine while others refused the pneumococcal vaccine. However, there was no supporting documentation in their records to confirm that informed consent or refusal was obtained, or that education about the benefits and potential side effects was provided. The DON confirmed that the required immunization consents and refusals could not be located, attributing the issue to missing documentation from the prior Infection Preventionist.
Failure to Maintain Pest-Free Food Service and Resident Areas
Penalty
Summary
The facility failed to ensure that food preparation and service areas, as well as resident rooms, were free from visible signs of insects, specifically flies. Observations included flies present in the dishwasher and kitchen areas, including near plates, food, and the tray line. Staff confirmed the presence of flies in these areas. Additionally, two residents reported ongoing issues with flies in their rooms, with one resident keeping a flyswatter on hand and another noting that a nurse had killed multiple flies in the room. The administrator acknowledged that while there was a QAPI initiative for flies and increased pest control services during certain months, there was no specific policy or procedure for pest control in place at the facility.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the survey and was based on a review of the resident's records and care planning documentation. The deficiency was directly related to the absence of a comprehensive, individualized care plan that included all necessary components to meet the resident's needs as required by regulations.
Failure to Provide Diet-Appropriate Food Texture and Preparation
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered Dysphagia Mechanical Soft Texture diet was served a regular meal consisting of uncut spaghetti noodles, regular sliced zucchini, and a regular slice of bread. The nurse aide questioned the appropriateness of the meal, noting the resident typically received pureed food, but the Regional Dietary Manager approved the tray as served. The resident was unable to eat the meal, expressing frustration and stating he could not eat the food due to not having teeth and was supposed to receive tomato soup, which was marked out on the tray ticket. Observations confirmed the food provided did not match the resident's dietary needs or the facility's diet order. Further investigation revealed the zucchini was not prepared according to the facility's recipe or the National Dysphagia Diet (NDD) guidelines. The zucchini was boiled, not baked, and was served in large, tough pieces that were difficult to chew and not consistent with the required texture for a mechanical soft diet. Staff interviews indicated a lack of adherence to recipes and menu guidelines, with some staff unaware of the existence of recipes or proper procedures for preparing food to meet specific diet consistencies. The facility's own diet manual and addendum specified requirements for chopped vegetables and mechanical soft diets, which were not followed in this instance.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to provide food in accordance with residents' documented preferences, allergies, and intolerances for three of thirteen residents reviewed. One resident did not receive a prescribed frozen nutritional supplement as indicated on their tray card, and the supplement was only provided after intervention by a state surveyor. Another resident, who reported a fish allergy, requested an alternate sandwich but was told there was no lunchmeat available and did not receive the requested cottage cheese and fruit, instead receiving chicken strips. Staff confirmed that the kitchen had been out of lunch meat for several days. A third resident, who had a documented dislike of pork, received a meal containing ham instead of the expected beef in a macaroni casserole. The resident reported having previously informed staff of this preference and resorted to eating a peanut butter and jelly sandwich instead. The Regional Dietary Manager confirmed that due to staffing issues and a missed food order, the facility had to make emergency substitutions, resulting in the use of ham in place of beef. These incidents demonstrate that the facility did not consistently accommodate residents' dietary needs and preferences as required.
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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